Clinical Applications of Nursing Diagnosis: Adult, Child...

Activity Intolerance [specify level], 283Activity Intolerance, risk for, 283Airway Clearance, ineffective, 292Allergy Response, latex, 70Allergy response, latex, risk for, 70Anxiety [specify level], 530Anxiety, death, 548Aspiration, risk for, 136Attachment, risk for impaired

parent/infant/child, 659Autonomic Dysreflexia, 299Autonomic Dysreflexia, risk for, 299

Body Image, disturbed, 541Body Temperature, risk for imbalanced, 139Bowel Incontinence, 236Breastfeeding, effective, 144Breastfeeding, ineffective, 148Breastfeeding, interrupted, 152Breathing Pattern, ineffective, 307

Cardiac Output, decreased, 313Caregiver Role Strain, 618Caregiver Role Strain, risk for, 618Communication, impaired verbal, 626Communication, readiness for enhanced, 626Conflict, parental role, 463Confusion, acute, 454Confusion, risk for acute, 454Confusion, chronic, 454Constipation, 240Constipation, perceived, 240Constipation, risk for, 240Coping, defensive, 771Coping, ineffective, 772Coping, readiness for enhanced, 767Coping, ineffective community, 756Coping, readiness for enhanced community, 756Coping, compromised family, 760Coping, disabled family, 760Coping, readiness for enhanced family, 767

Death Syndrome, risk for sudden infant, 111Decisional Conflict (specify), 463Denial, ineffective, 781Dentition, impaired, 155Development, risk for delayed, 353Diarrhea, 248Disuse Syndrome, risk for, 321Diversional Activity, deficient, 327

Energy Field, disturbed (revised), 36Environmental Interpretation Syndrome,

impaired, 469

Failure to Thrive, adult, 127Falls, risk for, 336Family Processes: alcoholism, dysfunctional, 635Family Processes, interrupted, 635Family Processes, readiness for enhanced, 635Fatigue, 340Fear (specify focus), 553Fluid Balance, readiness for enhanced, 158[Fluid Volume, deficient hyper/hypotonic]Fluid Volume, deficient [isotonic], 161Fluid Volume, excess, 167Fluid Volume, risk for deficient, 161Fluid Volume risk for imbalanced, 173

Gas Exchange, impaired, 346Grieving, 646Grieving, complicated, 654Grieving, risk for complicated, 654Growth, risk for disproportionate, 353Growth & Development, delayed, 353

Health Maintenance, ineffective, 42Health-Seeking Behaviors (specify), 49Home Maintenance, impaired, 360Hope, readiness for enhanced, 523Hopelessness, 562Hyperthermia, 176Hypothermia, 182

Identify, disturbed personal, 575Infant Behavior, disorganized, 365Infant Behavior, organized, readiness

for enhanced, 365Infant Behavior, risk for disorganized, 365Infant Feeding Pattern, ineffective, 186Infection, risk for, 54Injury, risk for, 59Injury, risk for perioperative positioning, 96Intracranial Adaptive Capacity, decreased, 450

Knowledge, deficient [Learning Need][specify], 474

Knowledge [specify], readiness for enhanced, 474

Lifestyle, sedentary, 381Loneliness, risk for, 569

Memory, impaired, 482Mobility, impaired bed, 304Mobility, impaired physical, 373Mobility, impaired wheelchair, 415

Nausea, 189Noncompliance, [Adherence, ineffective]

[specify], 80Nutrition, less than body requirements,

imbalanced, 194Nutrition, more than body requirements,

imbalanced, 204Nutrition, readiness for enhanced, 193Nutrition, more than body requirements, risk for

imbalanced, 204

Oral Mucous Membrane, impaired, 216

Pain, acute, 483Pain, chronic, 483Parenting, impaired, 662Parenting, readiness for enhanced, 662Parenting, risk for impaired, 662Perioperative Positioning, risk for, 96Peripheral Neurovascular Dysfunction, risk for, 370Poisoning, risk for, 60Post-Trauma Syndrome [specify stage], 785Post-Trauma Syndrome, risk for, 785Powerlessness [specify level], 579Powerlessness, risk for, 579Protection, ineffective, 100

Rape-Trauma Syndrome, 717Rape-Trauma Syndrome: compound reaction, 717Rape-Trauma Syndrome: silent reaction, 717Religiosity, impaired, 802Religiosity, risk for impaired, 802Religiosity, readiness for enhanced, 807Relocation Stress Syndrome, 673Relocation Stress Syndrome, risk for, 673Role Performance, ineffective, 678

Self-Care Deficit: bathing/hygiene, 386Self-Care Deficit: dressing/grooming, 386Self-Care Deficit: feeding, 386Self-Care Deficit: toileting, 386Self-Care, readiness for enhanced, 386Self-Concept, readiness for enhanced, 586Self-Esteem, chronic low, 590Self Esteem, situational low, 590Self Esteem, risk for situational low, 590Self-Mutilation, 598Self-Mutilation, risk for, 598

Sensory Perception, disturbed: (specify: visual,auditory, kinesthetic, gustatory, tactile,olfactory), 497

Sexual Dysfunction, 725Sexuality Pattern, ineffective, 731Skin Integrity, impaired, 216Skin Integrity, risk for impaired, 216Sleep, readiness for enhanced, 437Sleep Deprivation, 425Social Interaction, impaired, 684Social Isolation, 688Sorrow, chronic, 695Spiritual Distress, 812Spiritual Distress, risk for, 818Spiritual Well-Being, readiness for enhanced, 824Stress Overload, 740Suicide, risk for, 791Surgical Recovery, delayed, 107Swallowing, impaired, 209

Therapeutic Regimen Management, effective, 75Therapeutic Regimen Management, ineffective, 80Therapeutic Regimen Management, ineffective

community, 80Therapeutic Regimen Management, ineffective

family, 80Therapeutic Regimen Management, readiness for

enhanced, 92Thermoregulation, ineffective, 213Thought Processes, disturbed, 506Tissue Integrity, impaired, 216Tissue Perfusion, ineffective (specify type: cerebral,

cardiopulmonary, renal, gastrointestinal,peripheral), 396

Transfer Ability, impaired, 406

Unilateral Neglect Syndrome, 514Urinary Elimination, readiness for enhanced, 252Urinary Incontinence, functional, 254Urinary Incontinence, reflex, 254Urinary Incontinence, stress, 254Urinary Incontinence, total, 254Urinary Incontinence, urge, 255Urinary Incontinence, risk for urge, 255Urinary Retention [acute/chronic], 263

Ventilation, impaired spontaneous, 393Ventilatory Weaning Response, dysfunctional, 332Violence, [actual/] risk for other-directed, 700Violence, [actual/] risk for self-directed, 700

Walking, impaired, 408Wandering [specify sporadic or continual], 411

[ ] author recommendations

Used with permission from NANDA International:Definitions and Classification, 2007-2008. NANDA,Philadelphia, PA 2007

New from NANDA 2007-2008Blood Sugar, risk for unstableComfort, readiness for enhancedContaminationContamination, risk forDecision-Making, readiness for enhancedGlucose, risk for unstable levelHealth Behavior, risk proneHuman Dignity, risk for compromisedImmunization Status, readiness for enhancedInsomniaLiver Function, risk for impairedMoral DistressPower, readiness for enhancedSuffocation, risk forTrauma, risk forUrinary Elimination, impairedUrinary Incontinence, overflow

NURSING DIAGNOSESACCEPTED FOR USE AND RESEARCH (2007-2008)

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HEALTH PERCEPTION-HEALTHMANAGEMENT PATTERNDisturbed energy field, 36Effective therapeutic regimen management, 75Health-seeking behaviors (specify), 49Ineffective community therapeutic regimen

management, 80Ineffective family therapeutic regimen

management, 80Ineffective health maintenance, 42Ineffective protection, 100Ineffective therapeutic regimen management, 80Noncompliance (specify), 80Readiness for enhanced immunization status, 30Readiness for enhanced therapeutic regimen

management, 92Risk for falls, 336Risk for infection, 54Risk for injury (trauma), 59Risk for perioperative positioning injury, 96Risk for suffocation, 60Risk for poisoning, 60Sudden infant death syndrome, 111–115

NUTRITIONAL-METABOLIC PATTERNAdult failure to thrive, 127Deficient fluid volume, 161Effective breastfeeding, 144Excess fluid volume, 167Hyperthermia, 176Hypothermia, 182Imbalanced nutrition: more than body

requirements, 204Imbalanced nutrition: less than body

requirements, 194Impaired dentition, 155Impaired oral mucous membrane, 216Impaired skin integrity, 216Impaired swallowing, 209Impaired tissue integrity (specify type), 216Ineffective breastfeeding, 148Ineffective infant feeding pattern, 186Ineffective thermoregulation, 213Interrupted breastfeeding, 152Latex allergy response, 70Nausea, 189Readiness for enhanced fluid balance, 158Readiness for enhanced nutrition, 193Risk for aspiration, 136Risk for deficient fluid volume, 161Risk for imbalanced fluid volume, 173Risk for imbalanced body temperature, 139Risk for imbalanced nutrition: more than body

requirements, 204Risk for impaired skin integrity, 216Risk for latex allergy response, 70

ELIMINATION PATTERNBowel incontinence, 236Constipation, 240Diarrhea, 248Functional urinary incontinence, 254Perceived constipation, 240Readiness for enhanced urinary elimination, 252Reflex urinary incontinence, 254Risk for constipation, 240Risk for urge urinary incontinence, 255Stress urinary incontinence, 254Total incontinence, 254Urge urinary incontinence, 255Urinary retention, 263

ACTIVITY-EXERCISE PATTERNActivity intolerance, 283

Autonomic dysreflexia, 299Decreased cardiac output, 313Decreased intracranial adaptive capacity, 450Deficient diversonal activity, 327Delayed growth and development, 353Delayed surgical recovery, 107Disorganized infant behavior, 365Dysfunctional ventilatory weaning response, 331Fatigue, 340Impaired spontaneous ventilation, 393Impaired bed mobility, 304Impaired gas exchange, 346Impaired home maintenance, 360Impaired physical mobility, 373Impaired transfer ability, 406Impaired walking, 408Impaired wheelchair mobility, 415Ineffective airway clearance, 292Ineffective breathing pattern, 307Ineffective tissue perfusion (specify), 396Readiness for enhanced organized infant behavior, 365Readiness for enhanced self care, 386Risk for delayed development, 353Risk for disorganized infant behavior, 365Risk for disproportionate growth, 353Risk for activity intolerance, 283Risk for autonomic dysreflexia, 299Risk for disuse syndrome, 321Risk for peripheral neurovascular dysfunction, 370Sedentary lifestyle, 381Self-care deficit (specify: bathing/hygiene,

dressing/grooming, feeding, toileting), 386Wandering, 411

SLEEP-REST PATTERNDisturbed sleep pattern, 431Readiness for enhanced sleep, 437Sleep deprivation, 425

COGNITIVE-PERCEPTUALPATTERNAcute confusion, 454Acute pain, 483Chronic confusion, 454Chronic pain, 483Decisional conflict (specify), 463Deficient knowledge (specify), 474Disturbed sensory perception (specify), 497Disturbed thought processes, 506Impaired environmental interpretation

syndrome, 469Impaired memory, 480Readiness for enhanced knowledge (specify), 474Risk for acute confusion, 454Unilateral neglect, 514

SELF-PERCEPTION AND SELF-CONCEPT PATTERNAnxiety, 527Body image disturbed, 541Chronic low self-esteem, 590Death anxiety, 548Disturbed personal identity, 575Fear, 553Hopelessness, 562Powerlessness, 579Readiness for enhanced hope, 523Readiness for enhanced self-concept, 586Risk for loneliness, 569Risk for violence, self-directed, 700Risk for powerlessness, 579Risk for situational low self-esteem, 590Situational low self-esteem, 590

ROLE-RELATIONSHIP PATTERNAnticipatory grieving, 654Caregiver role strain, 618Chronic sorrow, 695Dysfunctional family processes: alcoholism, 635Dysfunctional grieving, 654Impaired parenting, 662Impaired social interaction, 684Impaired verbal communication, 626Ineffective role performance, 678Interrupted family processes, 635Parental role conflict, 662Readiness for enhanced communication, 626Readiness for enhanced family processes, 635Readiness for enhanced parenting, 662Relocation stress syndrome, 673Risk for caregiver role strain, 618Risk for violence directed at others, 700Risk for dysfunctional grieving, 654Risk for impaired parent/infant/child

attachment, 659Risk for impaired parenting, 662Risk for relocation stress syndrome, 673Social isolation, 688

SEXUALITY-REPRODUCTIVE PATTERNIneffective sexuality patterns, 731Rape-trauma syndrome, 717Rape-trauma syndrome: compound reaction, 717Rape-trauma syndrome: silent reaction, 717Sexual dysfunction, 718

COPING-STRESS TOLERANCEPATTERNCompromised family coping, 760Defensive coping, 771Disabled family coping, 760Impaired adjustment, 747Ineffective community coping, 756Ineffective coping, 772Ineffective denial, 781Post-trauma syndrome, 785Readiness for enhanced community coping, 756Readiness for enhanced coping, 767Readiness for enhanced family coping, 767Risk for self-mutilation, 598Risk for suicide, 791Risk for post-trauma syndrome, 785Self-mutilation, 598Stress overload, 740

VALUE-BELIEF PATTERNImpaired religiosity, 804Readiness for enhanced religiosity, 808Readiness for enhanced spiritual well-being, 824Risk for impaired religiosity, 804Risk for spiritual distress, 818Spiritual distress, 812

*Modified by Marjory Gordon, 2007, with permission.†New from NANDA 2007-2008ContaminationRisk for exposure to contaminationRisk for impaired liver functionRisk for unstable blood glucoseImpaired urinary eliminationOverflow urinary incontinenceReadiness for enhanced comfortReadiness for enhanced decision-makingReadiness for enhanced powerRisk for compromised human dignityMoral distress

GORDON’S FUNCTONALHEALTH PATTERNS*

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COX’S CLINICALAPPLICATIONS OFNURSING DIAGNOSIS

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COX’S CLINICALAPPLICATIONS OFNURSING DIAGNOSISAdult, Child, Women’s, Mental Health,Gerontic, and Home Health Considerations

Susan A. Newfield, PhD, RN, APRN, BCAssociate ProfessorWest Virginia UniversityMorgantown, West Virginia

Mittie D. Hinz, MSN, MBA, RNCPartnerDXT ConsultingSan Antonio, Texas

Program AdministratorHamot For WomenHamot Medical CenterErie, Pennsylvania

Donna Scott Tilley, RN, PhD, CNEAssociate ProfessorTexas Christian UniversityFort Worth, Texas

Kathryn L. Sridaromont, RN, C, MSNAssistant ProfessorTexas Tech University Health Sciences CenterLubbock, Texas

Patricia Joy Maramba, MSN, RN, APRN, BCSenior LecturerWest Virginia UniversityMorgantown, West Virginia

Fifth Edition

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Cox’s clinical applications of nursing diagnosis : adult, child, women’s, mental health,gerontic and home health considerations / Susan A. Newfield … [et al.]. — 5th ed.

p. ; cm.Rev. ed. of: Clinical applications of nursing diagnosis. 4th ed. c2002.Includes bibliographical references and index.ISBN-13: 978-0-8036-1655-4ISBN-10: 0-8036-1655-41. Nursing diagnosis. 2. Nursing assessment. 3. Nursing. I. Cox, Helen C. II. Newfield, Susan A.

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To Dr. Helen Cox, colleague, mentor, and friend, on her retirement. You took ambitious,

naive, young faculty members and turned us into authors and for that, we will be

eternally grateful.

To the memory of Dr. Mary Ann Lubno, colleague and friend.

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PREFACE TO THE FIFTH EDITION

Although the fifth edition of this book has seen many author changes, our commitmentand direction was clearly stated by, Dr. Helen Cox, in the preface to the fourth edition. Wecontinue our commitment to providing a nursing focus to the process of nursing care.

The fifth edition reflects seventeen new and six revised diagnoses accepted byNANDA in 2003 and 2005 and updated information in each chapter. The chapter formatsremain the same. We have revised the integration of NANDA, NIC, and NOC terminologyto assist with understanding their integration. NANDA, NIC, and NOC concepts areplaced in charts which identify the linkages that can be found at the beginning of eachchapter. Evaluation guidance has also been revised. We provided a master evaluation flowchart in Chapter 1 rather than providing one at the end of each care plan.

Two significant trends have impacted the practice of nursing since the fourth edition;decreasing length of stay and increased emphasis on evidence based practice. The lengthof stay continues to decrease and this is reflected in our revision of goals, interventions,and discharge planning. As we developed care plans, current average length of stay for thesetting was the litmus test for our selection of interventions. The interventions for eachdiagnosis reflect both current research in the area and recommended NIC interventions.

If you are new to nursing diagnosis, we encourage you to begin your journey withreading Chapter 1. Taking a few minutes to do this will provide you with an understandingof the authors’ thought processes that will facilitate your use of the book.

We continue to appreciate the comments from nursing faculty, staff and studentswho use the book. Your thoughtful comments have inspired each edition and we urge youto continue to support us in this way. It is our sincerest wish that this book will continueto provide a map for your journey in providing excellent client care.

Susan A. Newfield, PhD, RN, APRN, BC

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PREFACE TO THE FOURTH EDITION

The North American Nursing Diagnosis Association (NANDA) has been identifying, clas-sifying, and testing diagnostic nomenclature since the early 1970s. In our opinion, use ofnursing diagnosis helps define the essence of nursing and give direction to care that isuniquely nursing care.

If nurses (in all instances we are referring to registered nurses) enter the medicaldiagnosis of, for example, acute appendicitis as the patient’s problem, they have metdefeat before they have begun. A nurse cannot intervene for this medical diagnosis; inter-vention requires a medical practitioner who can perform an appendectomy. However, ifthe nurse enters the nursing diagnosis “Pain,” then a number of nursing interventionscome to mind. Several books incorporate nursing diagnosis as a part of planning care.However, these books generally focus outcome and nursing interventions on the relatedfactors; that is, nursing interventions deal with resolving, to the extent possible, thecausative and contributing factors that result in the nursing diagnosis. We have chosen tofocus nursing intervention on the nursing diagnosis. To focus on the nursing diagnosispromotes the use of concepts in nursing rather than concentrating on a multitude ofspecifics. For example, there are common nursing measures that can be used to relievepain regardless of the etiologic pain factor involved. Likewise, the outcomes focus on thenursing diagnosis. The main outcome nurses want to achieve when working with the nurs-ing diagnosis Pain is control of the patient’s response to pain to the extent possible. Again,the outcome allows the use of a conceptual approach rather than a multitude-of-specificsapproach. To clarify further, consider again the medical diagnosis of appendicitis. Thephysician’s first concern is not related to whether the appendicitis is caused by a fecalith,intestinal helminths, or Escherichia coli run amok. The physician focuses first on interven-ing for the appendicitis, which usually results in an appendectomy. The physician will dealwith etiologic factors following the appendectomy, but the appendectomy is the first levelof intervention. Likewise, the nurse can deal with the related factors through nursingactions, but the first level of intervention is directed to resolving the patient’s problem asreflected by the nursing diagnosis. With the decreasing length of stay for the majority ofpatients entering a hospital, we may indeed do well to complete the first level of nursingactions.

Additionally, there is continuing debate among NANDA members as to whether thecurrent list of diagnoses that are accepted for testing are nursing diagnoses or a list ofdiagnostic categories or concepts. We, therefore, have chosen to focus on concepts. Usinga conceptual approach allows focus on independent nursing functions and helps avoidfocusing on medical intervention. This book has been designed to serve as a guide tousing NANDA-accepted nursing diagnoses as the primary base for the planning of care.The expected outcomes, target dates, nursing actions, and evaluation algorithms (flow-charts) are not meant to serve as standardized plans of care but rather as guides and refer-ences in promoting the visibility of nursing’s contribution to health care.

Marjory Gordon’s Functional Health Patterns are used as an organizing frameworkfor the book. The Functional Health Patterns allow categorizing of the nursing diagnosesinto specific groups, which, in our opinion, promotes a conceptual approach to assessmentand formulation of a nursing diagnosis.

Chapter 1 serves as the overview-introductory chapter and gives basic contentrelated to the process of planning care and information regarding the relationship betweennursing process and nursing models (theories). Titles for Chapters 2 through 12 are takenfrom the functional patterns. Included in each of these chapters is a list of diagnoseswithin the pattern, a pattern description, pattern assessment, conceptual information, anddevelopmental information related to the pattern.

The pattern description gives a succinct summary of the pattern’s content and assistsin explaining how the diagnoses within the pattern are related. The list of diagnoses within

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the pattern is given to simplify location of the diagnoses. The pattern assessment serves topinpoint information from the initial assessment base and was specifically written to directthe reader to the most likely diagnosis within the pattern. Each assessment factor isdesigned to allow an answer of “yes” or “no.” If the patient’s answer or signs are indica-tive of a diagnosis within the pattern, the reader is directed to the most likely diagnosis ordiagnoses. The conceptual and developmental information is included to provide a quick,ready reference to the physiologic, psychological, sociologic, and age-related factors thatcould cause modification of the nursing actions in order to make them more specific foryour patient. The conceptual and developmental information can be used to determine therationale for each nursing action.

Each nursing diagnosis within the pattern is then introduced with accompanyinginformation of definition, defining characteristics, and related factors. We have added asection titled “Related Clinical Concerns.” This section serves to highlight the most com-mon medical diagnoses or cluster of diagnoses that could involve the individual nursingdiagnosis.

Immediately after the related clinical concerns section is a section titled “Have youselected the correct diagnosis?” This section was included as a validation check becausewe realize that several of the diagnoses appear very closely related and that it can be diffi-cult to distinguish between them. This is, in part, related to the fact that the diagnoseshave been accepted for testing, not as statements of absolute, discrete diagnoses. Thus,having this section assists the reader in learning how to pinpoint the differences betweendiagnoses and in feeling more comfortable in selecting a diagnosis that most clearlyreflects a patient’s problem area that can be helped by nursing actions.

After the diagnosis validation section is an outcome. The expected outcome servesas the end point against which progress can be measured. Different agencies may call theexpected outcome an objective, a patient goal, or an outcome standard. Readers may alsochoose to design their own patient-specific expected outcome using the given expectedoutcome as a guideline.

Target dates are suggested following the expected outcome. The target dates do notindicate the time or day the outcome must be fully achieved; instead, the target date signi-fies the time or day when evaluation should be completed in order to measure the patient’sprogress toward achievement of the expected outcome. Target dates are given in referenceto short-term care. For home health, particularly, the target date would be in terms ofweeks and months rather than days.

Nursing actions/interventions and rationales are the next information given. In mostinstances, the adult health nursing actions serve as the generic nursing actions. Subsequentsets of nursing actions (child health, women’s health, psychiatric health, gerontic health,and home health) show only the nursing actions that are different from the generic nursingactions. The different nursing actions make each set specific for the target population, butmust be used in conjunction with the adult health nursing actions to be complete.Rationales have been included to assist the student in learning the reason for particularnursing actions. Although some of the rationales are scientific in nature, that is, supportedby documented research, other rationales could be more appropriately termed “commonsense” or “usual practice rationales.” These rationales are reasons nurses have cited forparticular nursing actions and result from nursing experience, but research has not beenconducted to document these rationales. After the home health actions, evaluation algo-rithms are shown that help judge the patient’s progress toward achieving the expected out-come.

Evaluation of the patient’s care is based on the degree of progress the patient hasmade toward achieving the expected outcome. For each stated outcome, there is an evalua-tion flowchart (algorithm). The flowcharts provide minimum information, but demonstratethe decision-making process that must be used.

In all instances, the authors have used the definitions, defining characteristics, andrelated factors that have been accepted by NANDA for testing. A grant was provided toNANDA by the F. A. Davis Company for the use of these materials. All these materialsmay be ordered from NANDA (1211 Locust Street, Philadelphia, PA 19107). Likewise, a

x Preface to the Fourth Edition

••••••

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fee was paid to Mosby for the use of the domains and classes from McCloskey, JC, andBulechek, GM (eds): Nursing Interventions Classification (NIC), edition 3 (Mosby, St.Louis, 2000) and Johnson, M, Maas, M, and Moorhead, S (eds): Nursing OutcomesClassification, edition 2 (Mosby, St. Louis, 2000).

In some instances, additional information is included following a set of nursingactions. The additional information includes material that either needs to be highlighted ordoes not logically fall within the defined outline areas.

Throughout the nursing actions we have used the terms patient and client inter-changeably. The terms refer to the system of care and include the individual as well as thefamily and other social support systems. The nursing actions are written very specifically.This specificity aids in communication between and among nurses and promotes consis-tency of care for the patient.

There has been a tremendous increase in the activity of NANDA. In 1998 alone, 16new diagnoses were accepted, 32 diagnoses were revised, and one diagnosis was deleted.The official journal of NANDA became an international journal in 1999.

The fourth edition incorporates new and revised diagnoses from both the Thirteenth(1998) and Fourteenth (2000) NANDA Conferences. The proposed NANDA Taxonomy 2has been inserted to replace the old Taxonomy 1, Revised. The Nursing InterventionsClassification (NIC) system and the Nursing Outcomes Classification (NOC) systemdomains and classes have been incorporated.

Other revisions have been made to be consistent with current NANDA thought andpublications. One example is the deletion of major and minor defining characteristics andtheir assimilation under one heading of “Defining Characteristics.”

We continue to appreciate the feedback we have received from various sources andurge you to continue to assist us in this way. It is our sincerest wish that this book willcontinue to assist nurses and nursing students in their day-to-day use of nursing diagnosis.

Helen C. Cox, RN, C, EdD, FAAN

Preface to the Fourth Edition xi

••••••

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ACKNOWLEDGMENTS

The publication of a book necessitates the involvement of many persons beyond theauthors. We wish to acknowledge the support and assistance of the following persons whoindeed made this book possible:

Our families and friends, who supported our taking time away from life activities.

Joanne DaCunha, Publisher, Nursing, F. A. Davis, who has provided patient directiontoward our goal.

Bob Martone, Publisher, Nursing, F. A. Davis, for his continuing enthusiasm and belief inthe book.

Our students and colleagues, who consistently challenge us to rethink each care plan andhold us to exacting standards.

AND

A special acknowledgment to Dr. Marjory Gordon, a most gracious lady who freelyshared ideas, materials, support, and encouragement.

To each of these persons we wish to say a heartfelt “Thank you.” Please accept our deep-est gratitude and appreciation.

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REVIEWERS

Lenora D. Follett, RN, MSAssociate ProfessorPacific Union CollegeAngwin, California

Mary Haase, RN, MSNursing InstructorBlackhawk Technical CollegeJanesville, Wisconsin

Margaret Konieczny, RN, MSNWestern Nevada Community CollegeCarson City, Nevada

Tammie McCoy, RN, MSN, PhDAssistant ProfessorMississippi University for WomenColumbus, Mississippi

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CONTENTS

CHAPTER 1 INTRODUCTION 1

WHY THIS BOOK? 2

THE NURSING PROCESS 2Purpose 2Definition 3Role in Planning Care 3Care Plan versus Planning of Care 5

NURSING PROCESS STEPS 5Assessment 5Diagnosis 7Planning 8Implementation 9Documentation 11Evaluation 13

NURSING PROCESS AND CONCEPTUALFRAMEWORKS 14

Nursing Models 14Patterns 14

VALUE PLANNING OF CARE ANDCARE PLANS 22

SUMMARY 23

CHAPTER 2 HEALTH PERCEPTION–HEALTH MANAGEMENT PATTERN 25

PATTERN DESCRIPTION 26

PATTERN ASSESSMENT 26

CONCEPTUAL INFORMATION 26

DEVELOPMENTAL CONSIDERATIONS 29

APPLICABLE NURSING DIAGNOSES 36Energy Field, Disturbed 36Health Maintenance, Ineffective 42Health-Seeking Behaviors (Specify) 49Infection, Risk for 54Injury, Risk for 59Latex Allergy Response, Risk for and Actual 70Management of Therapeutic Regimen,

Effective 75Management of Therapeutic Regimen

(Individual, Family, Community), Ineffective 80Management, Readiness for Enhanced

Therapeutic Regimen 92Perioperative-Positioning Injury, Risk for 96Protection, Ineffective 100

xvii

Surgical Recovery, Delayed 107Sudden Infant Death Syndrome,

Risk for 111

CHAPTER 3 NUTRITIONAL–METABOLIC

PATTERN 119





APPLICABLE NURSING DIAGNOSES 131Adult Failure to Thrive 131Aspiration, Risk for 135Body Temperature, Imbalanced,

Risk for 139Breastfeeding, Effective 144Breastfeeding, Ineffective 148Breastfeeding, Interrupted 152Dentition, Impaired 155Fluid Balance, Readiness for Enhanced 158Fluid Volume, Deficient, Risk for

and Actual 161Fluid Volume, Excess 167Fluid Volume, Imbalanced,

Risk for 173Hyperthermia 176Hypothermia 182Infant Feeding Pattern, Ineffective 186Nausea 189Nutrition, Readiness for Enhanced 192Nutrition, Imbalanced, Less Than Body

Requirements 194Nutrition, Imbalanced, More Than Body

Requirements, Risk for and Actual 204Swallowing, Impaired 209Thermoregulation, Ineffective 213Tissue Integrity, Impaired 216

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CHAPTER 4 ELIMINATION

PATTERN 229





APPLICABLE NURSING DIAGNOSES 236Bowel Incontinence 236Constipation, Risk for, Actual, and Perceived 240Diarrhea 248Readiness for Enhanced Urinary Elimination 252Urinary Incontinence 254Urinary Retention 263

CHAPTER 5 ACTIVITY–EXERCISE

PATTERN 269





APPLICABLE NURSING DIAGNOSES 283Activity Intolerance, Risk for and Actual 283Airway Clearance, Ineffective 292Autonomic Dysreflexia, Risk for and Actual 299Bed Mobility, Impaired 304Breathing Pattern, Ineffective 307Cardiac Output, Decreased 313Disuse Syndrome, Risk for 321Diversional Activity, Deficient 327Dysfunctional Ventilatory Weaning Response

(DVWR) 331Falls, Risk for 336Fatigue 340Gas Exchange, Impaired 346Growth and Development, Delayed;

Disproportionate Growth, Risk for; DelayedDevelopment, Risk for 353

Home Maintenance, Impaired 360Infant Behavior, Disorganized, Risk

for and Actual, and Readiness for EnhancedOrganized 365

Peripheral Neurovascular Dysfunction,Risk for 370

Physical Mobility, Impaired 373Sedentary Lifestyle 381Self-Care Deficit (Feeding, Bathing-Hygiene,

Dressing-Grooming, Toileting) 386Spontaneous Ventilation, Impaired 393Tissue Perfusion, Ineffective (Specify Type: Renal,

Cerebral, Cardiopulmonary, Gastrointestinal,Peripheral) 396

Transfer Ability, Impaired 406Walking, Impaired 408Wandering 411Wheelchair Mobility, Impaired 415

CHAPTER 6 SLEEP–REST

PATTERN 421





APPLICABLE NURSING DIAGNOSES 425Sleep Deprivation 425Sleep Pattern, Disturbed 431Sleep, Readiness for Enhanced 437

CHAPTER 7 COGNITIVE–PERCEPTUAL

PATTERN 441





APPLICABLE NURSING DIAGNOSES 450Adaptive Capacity, Intracranial,

Decreased 450Confusion, Acute and Chronic 454Decisional Conflict (Specify) 463Environmental Interpretation Syndrome,

Impaired 469Knowledge, Deficient (Specify) 474Knowledge, Readiness for Enhanced 479Memory, Impaired 482Pain, Acute and Chronic 486Sensory Perception, Disturbed (Specify: Visual,

Auditory, Kinesthetic, Gustatory, Tactile,Olfactory) 497

Thought Process, Disturbed 506Unilateral Neglect 514

CHAPTER 8 SELF–PERCEPTION AND

SELF–CONCEPT PATTERN 519





APPLICABLE NURSING DIAGNOSES 530

xviii Contents

••••••

00Newfield (F)-FM 4/18/07 7:31 PM Page xviii

Anxiety 530Body Image, Disturbed 541Death Anxiety 548Fear 553Hopelessness 562Loneliness, Risk for 569Personal Identity, Disturbed 575Powerlessness, Risk for and Actual 579Self-Concept, Readiness for

Enhanced 586Self-Esteem, Chronic Low, Situational Low, and

Risk for Situational Low 590Self-Mutilation, Risk for and Actual 598

CHAPTER 9 ROLE—RELATIONSHIP

PATTERN 605





APPLICABLE NURSING DIAGNOSES 618Caregiver Role Strain, Risk for and Actual 618Communication, Impaired Verbal and Readiness

for Enhanced 626Family Processes, Interrupted, and Family

Processes, Dysfunctional: Alcoholism andReadiness for Enhanced 635

Grieving, Anticipatory 646Grieving, Dysfunctional, Risk for and Actual 654Parent, Infant, and Child Attachment, Impaired,

Risk for 659Parenting, Impaired, Risk for and Actual,

Readiness for Enhanced and Parental RoleConflict 662

Relocation Stress Syndrome, Risk for andActual 673

Role Performance, Ineffective 678Social Interaction, Impaired 684Social Isolation 688Sorrow, Chronic 695Violence, Self-Directed and Other-Directed, Risk

for 700

CHAPTER 10 SEXUALITY–REPRODUCTIVE PATTERN 713





APPLICABLE NURSING DIAGNOSES 717

Rape-Trauma Syndrome: Compound Reaction andSilent Reaction 717

Sexual Dysfunction 725Sexuality Patterns, Ineffective 731

CHAPTER 11 COPING–STRESS

TOLERANCE PATTERN 739





APPLICABLE NURSING DIAGNOSES 747Adjustment, Impaired 747Community Coping, Ineffective and Readiness for

Enhanced 756Family Coping, Compromised and Disabled 760Family Coping, Readiness for Enhanced 767Coping, Ineffective and Readiness for

Enhanced 771Post-Trauma Syndrome, Risk for and Actual 785Suicide, Risk for 791

CHAPTER 12 VALUE–BELIEF

PATTERN 799





APPLICABLE NURSING DIAGNOSES 804Religiosity, Impaired 804Religiosity, Readiness for Enhanced 808Religiosity, Risk for Impaired 811Spiritual Distress, 812Spiritual Distress, Risk for 818Spiritual Well-Being, Readiness for

Enhanced 824

APPENDIX A: NANDA’S AXES

DEFINITIONS 829

APPENDIX B: ADMISSION ASSESSMENT

FORM AND SAMPLE 831

INDEX 853

Contents xix

••••••

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INTRODUCTION

1

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WHY THIS BOOK?

When the first edition of this book was published, all theauthors were faculty members at the same school of nursing.We had become frustrated with the books that were availablefor teaching nursing diagnosis and found that the studentswere also expressing some of the same frustration.

The students felt they needed to bring several books tothe clinical area because the books for nursing diagnosis hadlimited information on pathophysiology and psychosocial ordevelopmental factors that had an impact on individualizedcare planning. The students were also confused regardingthe different definitions, defining characteristics, and relatedfactors each of the authors used. They were having difficultywriting individualized nursing actions for their patientsbecause the various authors appeared to focus on specificsrelated to the etiology or signs and symptoms of the nursingdiagnosis rather than on the concept represented by the nurs-ing diagnosis that had been emphasized to our students. Theauthors were also concerned about the number of books ourstudents had to buy, because most books focused on just oneclinical area, such as adult health or pediatrics. Thus, as thestudents progressed through the school, they had to buy dif-ferent books for different clinical areas even though each ofthe books had the common theme of the use of nursing diag-nosis. Another concern we, as faculty, had was the lack ofinformation in the various books regarding the final phase ofthe nursing process—evaluation. This most vital phase wasmentioned only briefly, and very little guidance was givenon how to proceed through this phase.

The final concern that led to the writing of the bookwas our desire to focus on nursing actions and nursing care,not medical care and medical diagnosis. We strongly believeand support the vital role of nurses in the provision of healthcare for our nation, and so we have focused strictly on nurs-ing in this book. After all, the majority of health-careproviders are nurses, and statistics consistently show thegeneral public has high respect for them.1 In a 2004 pollconducted by USA Today,2 the public considered nursingthe most honest profession and trusted the informationthat nurses give them. This increases the importance ofutilizing a standard nursing language to provide the founda-tion for quality nursing care and continued development ofevidence-based practice.

For these reasons, we have written this book particu-larly geared to student use. Specifically, we wrote the firstbook to assist students in learning how to apply nursingdiagnosis in the clinical area. By using the framework of thenursing process and the materials generated by the NorthAmerican Nursing Diagnosis Association International(NANDA),3 we believe this book makes it easier for you, thestudent, to learn and use nursing diagnosis in planning carefor your patients. (Nursing diagnoses were developed byand used with permission of North American NursingDiagnosis Association.3)

Since the writing of that first book, NANDA hasgrown to become an international organization with nursing

contributions from many countries and an alliance betweenNANDA International, the Nursing Interventions Classifica-tion (NIC),4 and Nursing Outcomes Classification (NOC),5

which resulted in the creation of the NANDA, NIC, andNOC (NNN) Taxonomy of Nursing Practice. This taxonomywas based on a modified framework of Gordon’s6 functionalhealth patterns with “the final taxonomic structure less likeGordon’s original, but with reduced misclassification errorsand redundancies to near zero.”3 Taxonomy II has been rec-ognized as an international nursing language. Designed to bemultiaxial in form, it provides greater flexibility of nomen-clature and allows for easy additions and modifications, thusproviding a more clinically useful tool that better supportsnursing practice. In spite of these revisions, some in nursingservice organizations continue to view Nursing Diagnosis asan academic exercise, good for students to learn, but highlyimpractical in the fast-paced world of nursing operations.When service settings utilize nursing diagnosis, it is mostoften in electronic documentation systems. The care plans inthese systems are most often standardized and demonstratelittle adaptation to the individual or their health status. Areview of the documentation shows that once a diagnosis ischosen the care plan is not updated during the contact withthe patient. Care planning, involving telling the computerthat the nurse saw the patient during that shift and looked atthe care plan to determine whether it was still pertinent, sim-ply becomes a “task” the nurse must perform. The multiax-ial format of Taxonomy II can provide the clinician with thetools necessary to better format his or her clinical documen-tation, showing the “whole picture” of diagnosis, treatment,evaluation, re-evaluation, and nursing outcomes.

It is however, important that this tool be used cor-rectly. “Using a multiaxial structure allows many diagnosesto be constructed that have no defining characteristics andmay even be nonsense.”3 For this reason the authors of thisbook felt that it was important to continue to provideNANDA, NIC and NOC, and the NNN Taxonomy of nurs-ing practice in this fifth edition. This inclusion will hope-fully better clarify the work and give not only the academicsetting, but also the clinical setting a guide that will providethe individual student and practitioner a resource that leadsto better understanding and operational use of nursing diag-noses and, ultimately, better patient outcomes. To facilitatethis integration we have provided charts in each chapter thatprovide basic links between the taxonomies.

THE NURSING PROCESS

PURPOSE

Gordon7 indicates that Lydia Hall was one of the first nursesto use the term nursing process in the early 1950s. Since thattime, the term nursing process has been used to describe theaccepted method of delivering nursing care. Iyer, Taptich,and Bernocchi-Losey state, “The major purpose of the nurs-ing process is to provide a framework within which the indi-vidualized needs of the client, family, and community can be

2 Introduction

••••••


met.”8 Today, the concept of the nursing process hasexpanded to include critical thinking processes that con-tribute to the decisions needed to choose the correct methodof delivering nursing care.9 The nursing process is utilized bynursing education to teach critical thinking, by professionalnursing organizations to test performance (NCLEX and spe-cialty certification exams), and by acute care institutions as abasis for care plans and critical pathways.10

It may be easier to think of a framework as a blueprintor outline that guides the planning of care for a patient.* AsDoenges and Moorhouse write,11 “The nursing process iscentral to nursing actions in any setting because it is an effi-cient method of organizing thought processes for clinicaldecision making and problem solving.” Use of the nursingprocess framework is beneficial for both the patient and thenurse because it helps ensure that care is planned, individu-alized, and reviewed over the period of time that the nurseand patient have a professional relationship. It must beemphasized that patient involvement is required throughoutall phases of the nursing process. If the patient is not involvedin all phases, then the plan of care is not individualized.

DEFINITION

Alfaro12 defines the nursing process as “an organized, sys-tematic method of giving individualized nursing care thatfocuses on identifying and treating unique responses of indi-viduals or groups to actual or potential alterations in health.”This definition fits very nicely with the American NursesAssociation (ANA) Social Policy Statement.13 “Nursing is

the protection, promotion, and optimization of health andabilities, prevention of illness and injury, alleviation ofsuffering through the diagnosis and treatment of humanresponses, and advocacy in the care of individuals, families,communities, and populations.” Alfaro’s definition is furthersupported by the ANA Nursing: Scope and Standardsof Practice14 (Table 1.1), practice standards written by sev-eral boards of Nursing in the United States, and the defi-nition of nursing that is written into the majority of nursepractice acts in the United States. (The standards of NursingPractice of the State of Texas are used as an example.15

See Table 1.2.)Basically, the nursing process provides each nurse a

framework to utilize in working with the patient. Theprocess begins at the time the patient needs assistance withhealth care, and continues until the patient no longer needsassistance to meet health-care maintenance. The nursingprocess utilizes the cognitive (intelligence, critical thinking,and reasoning), psychomotor (physical), and affective (emo-tion and values) skills and abilities a nurse needs to plan carefor a patient.

ROLE IN PLANNING CARE

Perhaps the most important question is, why do we need toplan care? There are several answers to this question, rang-ing from consideration of a patient’s individual needs to thelegal aspects of nursing practice.

First, the patient has a right to expect that the nursingcare received will be complete, safe, and of high quality. Ifplanning is not done, then gaps are going to exist in the care,impacting patient outcomes. At this time, patients are beingadmitted to the hospital more acutely ill than in the past, andare also being discharged into their communities more seri-ously ill. We are now caring for patients in a general med-

The Nursing Process 3

••••••

*Throughout this book we use the terms patient and client interchangeably.In most instances these terms refer to the individual who is receiving nurs-ing care. However, a patient can also be a community, such as in the com-munity–home health nursing actions, or a family, such as for the nursingdiagnosis Ineffective Family Coping, Compromised.

T A B L E 1 . 1 Standards of Care

Standard I. Assessment: The registered nurse collects comprehensive data pertinent to the patient’s health or thesituation.

Standard II. Diagnosis: The registered nurse analyzes the assessment data to determine diagnoses or issues.

Standard III. Outcome Identification: The registered nurse identifies expected outcomes for a plan individualized tothe patient or the situation.

Standard IV. Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attainexpected outcomes.

Standard V. Implementation: The registered nurse implements the identified plan.

Standard VI. Evaluation: The registered nurse evaluates progress toward attainment of outcomes.

Source: From American Nurses Association: Nursing: Scope and Standards of Practice. ANA, SilverSpring, MD, 2004, pp 21–32, with permission.


ical–surgical unit who would have been in a critical care unitten years ago. We are now sending patients home in 1 to 3days whom we previously would have kept in the hospitalanother 5 to 10 days. Procedures that required a 3- to 5-dayhospital stay in the past are now being performed in day sur-gery or outpatient facilities. A variety of factors have led tothis situation, including advances in technology; advent ofthe use of diagnosis related groups (DRGs) for patientbilling; managed care insurance plans; prospective paymentinsurance plans, capitated payment insurance plans; move-ment from acute care to longer term care settings such ashome health, nursing homes, and rehabilitation units; and,most importantly, the desire to contain the rapidly risingcosts of health care. These problems, which together havebeen labeled the “quicker, sicker” phenomenon, in combi-nation with a national shortage of registered nurses, havecreated a situation in which the contact time a professionalnurse has with a patient is being cut to a minimum. Giventhis set of circumstances, if care planning is not done thereis no doubt that gaps will exist in the nursing care given to apatient. Such care will be incomplete, inconsistent, unsafe,and certainly not of high quality, which will result in anincrease in negative outcomes.

Second, care planning and its documentation providea means of professional communication. This communica-tion promotes consistency of care for the patient and pro-vides a comfort level for the nurse. Any patient admitted toa health-care agency is going to have some level of anxiety.Imagine how this anxiety will increase when each nurse whoenters the room does each procedure differently, answersquestions differently, or uses different time lines for care(e.g., a surgical dressing that has been changed in the morn-ing every day since surgery is not changed until the after-noon). Care planning provides a comfort level for the nursebecause it gives the nurse a ready reference to help ensurethat care is complete. In addition, when the care is plannedusing practices with evidence that supports their use, con-sistency in implementation improves efficacy resulting inimproved patient outcomes. Care planning also provides a

guideline for documentation and promotes practicing withinlegally defined standards.

Third, care planning provides legal protection for thenurse. We are practicing in one of the most litigious societiesthat has ever existed. In the past, nurses were not frequentlynamed in legal actions; however, this has changed, as a briefreview of suits being filed would show. In a legal suit, nurs-ing care is measured against the idea of what a reasonablyprudent nurse would do in the same circumstances. Theaccepted standards of nursing practice, as published byANA (see Table 1.1) and the individual boards of nursing(see Table 1.2), are the accepted definitions of reasonable,prudent nursing care.

Finally, accrediting and approval agencies such as theJoint Commission on Accreditation of Healthcare Organiza-tions (JCAHO), the National League for Nursing Accredit-ing Commission (NLNAC), Medicare, and Medicaid havecriteria that specifically require documentation of planningof care. The accreditation status of a health-care agency candepend on consistent documentation that planning of carehas been done. Particularly with the third-party payers, suchas Medicare, Medicaid, and insurance companies, lack ofdocumentation regarding the planning and implementationof care results in no reimbursement for care. Ultimately,nonreimbursement for care leads to lack of new equipment,no pay raises, and, in some extreme cases, has led to hospi-tal closures.

With the advent of electronic documentation in theacute care setting and other nursing agencies (outpatientclinics, home health care, and departments of health) it hasbecome even more critical to possess knowledge andresources that allow practicing nurses in any setting to showthe progress from nursing diagnosis to nursing interventionsand finally the nursing outcomes in their documentation.Measurement of outcomes is the basis for measuring thequality, safety, and results of the care rendered to a patientor client and are today’s “yardstick” on which the generalpublic, regulatory agencies, and third-party payers base theirdecisions and actions.

4 Introduction

••••••

T A B L E 1 . 2 Standards of Nursing Practice

The registered nurse shall:1. Know and conform to the Texas Nurse Practice Act and the board’s rules and regulations as well as all federal, state,

or local laws, rules, or regulations affecting the RN’s current area of nursing practice;2. Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of health-care needs

of clients and shall:A. Utilize a systematic approach to provide individualized, goal-directed nursing care by:

i. performing comprehensive nursing assessments regarding the health status of the client;ii. making nursing diagnoses that serve as the basis for the strategy of care;

iii. developing a plan of care based on the assessment and nursing diagnosis;iv. implementing nursing care; andv. evaluating the client’s responses to nursing interventions.

Source: Adapted from Board of Nurse Examiners for the State of Texas: Standards of NursingPractice. Texas Nurse Practice Act. Author, Austin, TX, 2004, with permission.


CARE PLAN VERSUSPLANNING OF CARE

Revisions of nursing standards by JCAHO created questionsregarding the necessity of nursing care plans. According toBrider,16 Henry,17 and Webster,18 some authors predicted thedemise of the care plan, but review of the revised nursingstandards shows that the standards require not less, but moredetailed care planning documentation in the patient’s med-ical record.

The Joint Commission on Accreditation of HealthcareOrganizations (JCAHO), like all health-care organizations,is experiencing change. To better serve the public andhealth-care organizations, JCAHO dramatically changedits accreditation process in 2005. Rather than focusing onlyon “nursing process,” policies and procedures review, andother isolated factors within the organization, they nowfocus on the patients and their journey through the health-care system. This journey includes “Care, treatment, andservices provided through the successful coordination andcompletion of a series of processes that include appropri-ate initial assessment of needs; development of a plan forcare, treatment, and services; the provision of care, treat-ment, and services; ongoing assessment of whether the care,treatment, and services are meeting the patient’s needs andeither the successful discharge of the patient or referral ortransfer of the patient for continuing care, treatment, andservices.”19

Review of the new criteria indicates that the standardsrequire documentation related to not only the nursingprocess, but also the development and implementation ofa plan encompassing the provision of care, treatment, andservices provided the patient. Instead of defining plan, per se,the new guidelines define nursing care as: “Professionalprocesses of assessment, diagnosis, planning, implementa-tion, and evaluation based on the art and science of nursingto promote health, its recovery, or a peaceful and dignifieddeath.”19

This provision of care is still based on data gatheringduring patient assessment, which identifies the patient’scare needs, tests the strategy for providing services to meetthose needs, documents treatment goals or objectives, out-lines the criteria for terminating specified interventions,and documents the individual’s progress in meeting speci-fied goals and objectives. The elements that make up theprovision of care, as defined by JCAHO, are “related to eachother through an integrated and cyclical process that mayoccur over minutes, hours, days, weeks, months, or years,depending on the setting and the needs of the patient”19

(Fig. 1.1).Rather than eliminating care plans, the new JCAHO

requirements expand the concept and increase the impor-tance of the coordination and documentation of the patient’sjourney guided by nursing assessment. This documentationmust be in the medical record. The care plan is not dead;rather, it is revised to more clearly reflect the important roleof nursing assessment and planning in the patient’s care. No

longer a separate, often discarded, and irrelevant page, theplan of care is an integral part of the permanent record. Theflow sheets developed for this book offer guidelines for com-puterizing information regarding nursing care.

Faculty can use the revised JCAHO guidelines19 toassist students in developing expertise beyond writingextensive nursing care plans. This additional expertiserequires the new graduate to envision the patient’s journeythrough the health-care system and to integrate all phases ofthe nursing process into the permanent record. Rather thaneliminating the need for care planning and nursing diagno-sis, these standards have reinforced the importance of nurs-ing care and nursing diagnosis for not only nursing, but alsothe entire health-care organization.

NURSING PROCESS STEPS

There are five steps, or phases, in the nursing process: assess-ment, diagnosis, planning, implementation, and evaluation.These steps are not distinct; rather, they overlap and build oneach other. To carry out the entire nursing process, you mustbe sure to complete each step accurately and then build uponthe information in that step to complete the next one.

ASSESSMENT

The first step, or phase, of the nursing process is assessment.During this phase, you are collecting data (factual informa-tion) from several sources. The collection and organizationof these data allow you to:

1. Determine the patient’s current health status.2. Determine the patient’s strengths and problem areas

(both actual and potential).3. Prepare for the second step of the process—diagnosis.

Data Sources and TypesThe sources for data collection are numerous, but it is essen-tial to remember that the patient is the primary data source.No one else can explain as accurately as the patient can the

Nursing Process Steps 5

••••••

Assessment

Provis

ion

ofC

are C

oord

ination of Care

Adm

ission to Org

Dis

charge/Transfer

Planning ofC

are

F I G U R E 1 . 1 Provision of care system. (Source:JCAHO.)


start of the problem, the reason for seeking assistance or theexact nature of the problem, and the effect of the problem onthe patient. Other sources include the patient’s family or sig-nificant others; the patient’s admission sheet from the admit-ting office; the physician’s history, physical, and orders;laboratory and x-ray examination results; information fromother caregivers; and current nursing literature.

Assessment data can be further classified as types ofdata. According to Iyer and associates,8 the data types aresubjective, objective, historical, and current.

Subjective data are the facts presented by the patientthat show his or her perception, understanding, and interpre-tation of what is happening. An example of subjective datais the patient’s statement, “The pain begins in my lower backand runs down my left leg.”

Objective data are facts that are observable andmeasurable by the nurse. These data are gathered by thenurse through physical assessment, interviewing, and observ-ing, and involve the use of the senses of seeing, hearing,smelling, and touching. An example of objective data is themeasurement and recording of vital signs. Objective dataare also gathered through such diagnostic examinations aslaboratory tests, x-ray examinations, and other diagnosticprocedures.

Historical data refer to health events that happenedprior to this admission or health problem episode. An exam-ple of historical data is the patient statement, “The last timeI was in a hospital was 1996 when I had an emergencyappendectomy.”

Current data are facts specifically related to thisadmission or health problem episode. An example of thistype of data is vital signs on admission: T 99.2�F, P 78, R 18,BP 134/86. Please note, that just as there is overlapping ofthe nursing process steps, there is also overlapping of thedata types. Both historical and current data may be eithersubjective or objective. Historical and current data assist inestablishing time references and can give an indication ofthe patient’s usual functioning.

Essential SkillsAssessment requires the use of the skills needed for inter-viewing, conducting a physical examination, and observing.As with the nursing process itself, these skills are not usedone at a time. While you are interviewing the patient, youare also observing and determining physical areas thatrequire a detailed physical assessment. While completing aphysical assessment, you are asking questions (interview-ing) and observing the patient’s physical appearance as wellas the patient’s response to the physical examination.

Interviewing generally starts with gathering data forthe nursing history. In this interview, you ask for generaldemographic information such as name, address, date of lasthospitalization, age, allergies, current medications, and thereason the patient was admitted. Depending on the agency’sadmission form, you may then progress to other specificquestions or a physical assessment. An example of an

admission assessment specifically related to the FunctionalHealth Patterns is given in Appendix B.

The physical assessment calls for four skills: inspec-tion, palpation, percussion, and auscultation. Inspectionmeans careful and systematic observation throughout thephysical examination, such as observation for and recordingof any skin lesions. Palpation is assessment by feeling andtouching. Assessing the differences in temperature betweena patient’s upper and lower arm would be an example of pal-pation. Another common example of palpation is breast self-examination. Percussion involves touching, tapping, andlistening. Percussion allows determination of the size, den-sity, locations, and boundaries of the organs. Percussion isusually performed by placing the index or middle finger ofone hand firmly on the skin and striking with the middle fin-ger of the other hand. The resultant sound is dull if the bodyis solid under the fingers (such as at the location of the liver)and hollow if there is a body cavity under the finger (suchas at the location of the abdominal cavity). Auscultationinvolves listening with a stethoscope and is used to helpassess respiratory, circulatory, and gastrointestinal status.

The physical assessment may be performed using ahead-to-toe approach, a body system approach, or a func-tional health pattern approach. In the head-to-toe approach,you begin with the patient’s general appearance and vitalsigns. You then progress, as the name indicates, from thehead to the extremities.

The body system approach to physical assessmentfocuses on the major body systems. As the nurse is conduct-ing the nursing history interview, she or he will get a firmidea of which body systems need detailed examination. Anexample is a cardiovascular examination, in which the api-cal and radial pulses, blood pressure (BP), point of maxi-mum intensity (PMI), heart sounds, and peripheral pulsesare examined.

The functional health pattern approach is based onGordon’s Functional Health Patterns typology and allowsthe collection of all types of data according to each pattern.This is the approach used by this book and leads to three lev-els of assessment. First is the overall admission assessment,where each pattern is assessed through the collection ofobjective and subjective data. This assessment indicates pat-terns that need further attention, which requires implemen-tation of the second level of pattern assessment. The secondlevel of pattern assessment indicates which nursing diag-noses within the pattern might be pertinent to this patient,which leads to the third level of assessment, the definingcharacteristics for each individual nursing diagnosis. Havinga three-tiered assessment might seem complicated, but eachassessment is so closely related that completion of theassessment is easy. A primary advantage in using this typeof assessment is the validation it gives the nurse that theresulting nursing diagnosis is the most accurate diagnosis.Another benefit to using this type of assessment is thatgrouping of data is already accomplished and does not haveto be a separate step.

6 Introduction

••••••


Data GroupingData grouping simply means organizing the information intosets or categories that will assist you in identifying thepatient’s strengths and problem areas. A variety of organiz-ing frameworks is available, such as Maslow’s Hierarchy ofNeeds, Roy’s Adaptation Model, Gordon’s FunctionalHealth Patterns, and NANDA Taxonomy II.3 Each of thenursing theorists (e.g., Roy, Levine, and Orem)40,41 speaks toassessment within the framework of her theories. Organizingthe information allows you to both identify the appropriatefunctional health pattern and to spot any missing data. If youcannot identify the pertinent functional health pattern, thenyou need to collect further data. The goal of data grouping isto arrive at a nursing diagnosis.

DIAGNOSIS

Diagnosis means reaching a definite conclusion regardingthe patient’s strengths and human responses. This diagnosticprocess is complex and utilizes aspects of intelligence, think-ing, and critical thinking.9 When planning care, one must becognizant that “the diagnosis of human responses is a com-plex process involving the interpretation of human behaviorrelated to health.”9 Therefore the patient’s response andstrengths facilitate their adaptation during the implementa-tion phase. In this book, we use the diagnoses accepted byNANDA-I.

Nursing DiagnosisThe North American Nursing Diagnosis Association Interna-tional (NANDA-I), formerly the National Conference Groupfor Classification of Nursing Diagnosis, has been meetingsince 1973 to identify, develop, and classify nursing diag-noses. Setting forth a nursing diagnosis nomenclature artic-ulates nursing language, thus promoting the identification ofnursing’s contribution to health, and facilitates communica-tion among nurses. In addition, the use of nursing diagnosisprovides a clear distinction between nursing diagnosis andmedical diagnosis and provides clear direction for theremaining aspects of the planning of care.

NANDA accepted its first working definition of nurs-ing diagnosis in 1990.20 Nursing diagnosis is a clinical judg-ment about individual, family, or community responses toactual or potential health problems/life processes. Nursingdiagnoses provide the basis for selection of nursing interven-tions to achieve outcomes for which the nurse is accountable.

Much debate occurred during the Ninth Conferenceregarding this definition, and it is anticipated this debate willcontinue. The debate centers on a multitude of issues relatedto the definition, which are beyond the scope of this book.Readers are urged to consult the official journal of NANDA-I, Nursing Diagnosis: The International Journal of NursingLanguage and Classification, to keep up to date on thisdebate.

The definition of nursing diagnosis distinguishes nurs-ing diagnosis from medical diagnosis. For example, nursing

diagnosis is different from medical diagnosis in its focus.Kozier, Erb, and Olivieri21 write that nursing diagnosesfocus on patient response, whereas medical diagnoses focuson the disease process. As indicated by the definition ofnursing diagnosis, nurses identify the human responses toactual or potential health problems while physicians placeprimary emphasis on identifying current health problems.

Nursing diagnosis and medical diagnosis are similarin that the same basic procedures are used to derive the diag-nosis (i.e., physical assessment, interviewing, and observ-ing). Likewise, according to Kozier and associates,21 bothtypes of diagnoses are designed for essentially the same rea-son—planning care for a patient.

A nursing diagnosis is based on the presence of defin-ing characteristics. According to NANDA-I,3 defining char-acteristics are observable cues/inferences that cluster asmanifestations of an actual or wellness diagnosis. For actualnursing diagnoses (the problem is present), a majority of thedefining characteristics must be present. For risk diagnoses(risk factors indicate the problem might develop), the riskfactors must be present. Understanding defining characteris-tics improves your interpretation of human responses andassists you in making interpretations that are more accurate.This accuracy will result in implementation of interventionsthat have the greatest potential for the best outcomes. Yourmastery of nursing diagnosis will also increase the agree-ment between nurses about the client’s response and resultin consistent, quality care.

Diagnostic StatementsAccording to the literature, complete nursing diagnosticstatements include, at a minimum, the human response andan indication of the factors contributing to the response. Thefollowing is a rationale for the two-part statement: “Eachnursing diagnosis, when correctly written, can accomplishtwo things. One, by identifying the unhealthy response, ittells you what should change. . . And two, by identifying theprobable cause of the unhealthy response, it tells you what todo to effect change.”22

Although there is no consensus on the phrase thatshould be used to link the response and etiologic factors,perusal of current literature indicates that the most com-monly used phrases are related to, secondary to, and due to.

The phrase related to is gaining the most acceptancebecause it does not imply a direct cause-and-effect relation-ship. Kieffer23 believes using the phrases due to and second-ary to may reflect such a cause-and-effect relationship,which could be hard to prove. Thus, a complete nursingdiagnostic statement would read: Pain related to surgicalincision.

Gordon6 identifies three structural components of anursing diagnostic statement: The problem (P), the etiology(E), and signs and symptoms (S). The problem describes thepatient’s response or current state (the nursing diagnosis);the etiology describes the cause or causes of the response(related to); and the symptoms delineate the defining charac-


••••••


teristics or observable signs and symptoms demonstrated ordescribed by the patient. The S component can be readilyconnected to the P and E statements through the use of thephrase as evidenced by. Using this format, a complete nurs-ing diagnostic statement would read: Pain related to surgicalincision as evidenced by verbal comments and body posture.

As discussed in the preface, we recommend startingwith stating the nursing diagnosis only. Therefore, the nurs-ing diagnosis would be listed in the patient’s chart in thesame manner as it is given in the nomenclature: Pain.Remember that the objective and subjective data related tothe patient’s pain have already been recorded in the healthrecord in the assessment section, so there is no need torepeat it.

The nursing diagnostic statement examples given pre-viously describe the existence of an actual problem.Professional nurses are strong supporters of preventivehealth care—cases in which a problem does not yet exist andmeasures that can be taken to ensure that the problem doesnot arise. In such instances, the nursing diagnostic statementis prefaced by the words “Risk for.” Nursing diagnoses thatcarry the preface “Risk for” also carry with them risk factorsrather than defining characteristics.

Whereas other books include a variety of nursing diag-noses, this book uses only the actual and risk (formerlylabeled “potential”) diagnoses accepted by NANDA-I (30)for testing. Probable related factors (formerly “etiologic fac-tors”) are grouped, as are the defining characteristics (for-merly “signs and symptoms”), under each specific nursingdiagnosis. As indicated in the preface, nursing actions in thisbook reflect a conceptual approach rather than a specific (torelated factors or defining characteristics) approach.

To illustrate this approach, let us use the diagnosisPain. There are common nursing orders related to the inci-dence of pain regardless of whether the pain is caused bysurgery, labor, or trauma. You can take this conceptualapproach and make an individualized adaptation accordingto the etiologic factors affecting your patient and the reac-tion your patient is exhibiting to pain.

Identifying and specifying the nursing diagnoses leadsto the next phase of the process— planning. Now that youknow what the problems, responses, and strengths are, youcan decide how to resolve the problem areas while buildingon the strength areas.

PLANNING

Planning involves three subsets: setting priorities, writingexpected outcomes, and establishing target dates. Planningsets the stage for writing nursing actions by establishingwhere we are going with our plan of care. Planning furtherassists in the final phase of evaluation by defining the stan-dard against which we will measure progress.

Setting PrioritiesWith the sicker, quicker problem discussed earlier, you aregoing to find yourself in the situation of having identifiedmany more problems than can possibly be resolved in a 1-

to 3-day hospitalization (today’s average length of stay). Inthe long-term care facilities, such as home health, rehabili-tation, and nursing homes, long-range problem solving ispossible, but setting priorities of care is still necessary.

Several methods of assigning priorities are available.Some nurses assign priorities based on the life threat posedby a problem. For example, Ineffective Airway Clearancewould pose more of a threat to life than the diagnosis Riskfor Impaired Skin Integrity. Some nurses base their prioriti-zation on Maslow’s Hierarchy of Needs. In this instance,physiologic needs would require attention before socialneeds. One way to establish priorities is to simply ask thepatient which problem he or she would like to pay attentionto first. Another way to establish priorities is to analyze therelationships between problems. For example, a patient hasbeen admitted with a medical diagnosis of headaches andpossible brain tumor. The patient exhibits the defining char-acteristics of both Pain and Anxiety. In this instance, wemight want to implement nursing actions to reduce anxiety,knowing that if the anxiety is not reduced, pain controlactions will not be successful. Once priorities have beenestablished, you are ready to establish expected outcomes.

Expected OutcomesOutcomes, goals, and objectives are terms that are fre-quently used interchangeably because all indicate the endpoint we will use to measure the effectiveness of our planof care. Because so many published sets of standardsand JCAHO talk in terms of outcome standards or criteria,we have chosen to use the term “expected outcomes” inthis book.

Several authors23–25 give guidelines for writing clini-cally useful expected outcomes:

1. Expected outcomes are clearly stated in terms of patientbehavior or observable assessment factors.

E X A M P L E

POOR Will increase fluid balance by time of dis-charge.

GOOD Will increase oral fluid intake to 1500 mL per24 hours by 9/11.

2. Expected outcomes are realistic, achievable, safe, andacceptable from the patient’s viewpoint.

E X A M P L E

Mrs. Braxton is a 28-year-old woman who has delayedhealing of a surgical wound. She is to receive dischargeinstructions regarding a high-protein diet. She is a widowwith three children under the age of 10. Her only sourceof income is Social Security.POOR Will eat at least two 8-oz servings of steak

daily. [unrealistic, unachievable, unaccept-able, etc.]

GOOD Will eat at least two servings from the follow-ing list each day:

Lean ground meatEggs

8 Introduction

••••••


CheesePinto beansPeanut butterFishChicken

3. Expected outcomes are written in specific, concreteterms depicting patient action. NOC states that outcomesamong other things, should be:ConciseNot describe nurse behaviors or interventionsDescribe a state, behavior, or perception that is inher-ently variable and can be measured and quantified.13

E X A M P L E

POOR Maintains fluid intake by 9/11.GOOD Will drink at least 8-oz of fluid every hour

from 7 a.m. to 10 p.m. by 9/11.

4. Expected outcomes are directly observable by use of atleast one of the five senses.

E X A M P L E

POOR Understands how to self-administer insulinby 9/11.

GOOD Accurately return-demonstrates self-administration of insulin by 9/11.

5. Expected outcomes are patient centered rather thannurse centered.

E X A M P L E

POOR Teaches how to measure blood pressure by9/11.

GOOD Accurately measures own blood pressure by9/11.

Establishing Target DatesWriting a target date at the end of the expected outcomestatement facilitates the plan of care in several ways.19,23

1. Assists in “pacing” the care plan. Pacing helps keep thefocus on the patient’s progress.

2. Serves to motivate both patients and nurses towardaccomplishing the expected outcome.

3. Helps patient and nurse see accomplishments.4. Alerts nurse when to evaluate care plan.

Target dates can be realistically established by payingattention to the usual progress and prognosis connected withthe patient’s medical and nursing diagnoses. Additionalreview of the data collected during the initial assessmenthelps indicate individual factors to be considered in estab-lishing the date. For example, one of the previous expectedoutcomes was stated as “Accurately return-demonstratesself-administration of insulin by 9/11.”

The progress or prognosis according to the patient’smedical and nursing diagnosis will not be highly significant.The primary factor will be whether diabetes mellitus is a

new diagnosis for the patient or is a recurring problem for apatient who has had diabetes mellitus for several years.

For the newly diagnosed patient, we would probablywant our deadline day to be 5 to 7 days from the date oflearning the diagnosis. For the recurring problem, we mightestablish the target date to be 2 to 3 days from the date ofdiagnosis. The difference is, of course, the patient’s knowl-edge base.

Now look at an example related to the progress issue.Mr. Kit is a 19-year-old college student who was admittedearly this morning with a medical diagnosis of acute appen-dicitis. He has just returned from surgery following anappendectomy. One of the nursing diagnoses for Mr. Kitwould, in all probability, be Pain. The expected outcomecould be “uses oral analgesic relief measures by [date].” Inreviewing the general progress of a young patient withthis medical and nursing diagnosis, we know that generallyanalgesic requirements delivered by PCA start decreasingwithin 48 to 72 hours. Therefore, we would want to estab-lish our target date as 2 to 3 days following the day of sur-gery. This would result in the objective reading (assume dateof surgery was 11/1): “Will have discontinued use of PCAand will request oral pain medication as needed for analge-sia by 11/3.”

To further emphasize the target date, it is suggestedthat the date be underlined, highlighted by using a different-colored pen, or circled to make it stand out. Pinpointing thedate in such a manner emphasizes that evaluation ofprogress toward achievement of the expected outcomeshould be made on that date. Agencies which utilize elec-tronic documentation may have automatic stop or evaluativetimes programmed into their system. Remember that the tar-get date does not mean the expected outcome must be totallyachieved by that time; instead, the target date signifies theevaluation date.

Once expected outcomes have been written, you arethen ready to focus on the next phase—implementation.

IMPLEMENTATION

Implementation is the action phase of the nursing process.Recent literature has introduced the concept of nursing inter-ventions, which are defined as treatments based on clinicaljudgment and knowledge that a nurse performs to enhancepatient outcomes.4 These interventions are the concepts thatlink specific nursing activities and actions. The authors ofthis book chose to focus on specific “nursing actions” in theirplans of care rather than interventions to facilitate the stu-dent’s/practitioner’s development of individualized care.Two important steps are involved in implementation: Thefirst is determining the specific nursing actions that willassist the patient to progress toward the expected outcome,and the second is documenting the care administered.

Nursing action is defined as nursing behavior thatserves to help the patient achieve the expected outcome.Nursing actions include both independent and collaborativeactivities. Independent activities are those actions the nurse


••••••


performs, using his or her own discretionary judgment, thatrequire no validation or guidelines from any other health-care practitioner. An example is deciding which noninvasivetechnique to use for pain control or deciding when to teachthe patient self-care measures. Collaborative activities arethose actions that involve mutual decision making betweentwo or more health-care practitioners. For example, a physi-cian and nurse decide which narcotic to use when meperi-dine is ineffective in controlling the patient’s pain, or aphysical therapist and nurse decide on the most beneficialexercise program for a patient. Implementing a physician’sorder and referral to a dietitian are other common examplesof collaborative actions.

Written nursing actions guide both actual patient careand proper documentation, and they must therefore bedetailed and exact. Written nursing actions should be evenmore definite than what is generally found in physicianorders. For example, a physician writes the order, “Increaseambulation as tolerated” for a patient who has been immo-bile for 2 weeks. The nursing actions should reflect specifiedincrements of ambulation as well as ongoing assessment:

11/21. a. Prior to activity, assess BP, P, and R. After activ-ity assess: (1) BP, P, R; (2) presence/absenceof vertigo; (3) circulation; (4) presence/absenceof pain.

b. Assist to dangle on bedside for 15 minutes atleast 4 times a day on 11/2.

c. If BP, P, or R change significantly or vertigo ispresent or circulation is impaired or pain is pres-ent, return to supine position immediately.Elevate head of bed 30 degrees for 1 hour; then45 degrees for 1 hour; then 90 degrees for 1 hour.If tolerated with no untoward signs or symptoms,initiate order 1b again.

d. Assist up to chair at bedside for 30 minutes atleast 4 times a day on 11/3.

e. Assist to ambulate to bathroom and back at least4 times a day on 11/4.

f. Supervise ambulation of one-half length of hall atleast 4 times a day on 11/5 and 11/6.

g. Supervise ambulation of length of hall at least 4times a day on 11/7.S. J. Smith, RN

Nursing actions further differ from physician orders inthat the patient’s response is directly related to the imple-mentation of the action. It is rare to see a physician orderthat includes alternatives if the first order has minimal, neg-ative, or no effect on the patient. A complete written nursingaction incorporates at least the following five componentsaccording to Bolander.24

1. Date the action was initially written.2. A specific action verb that tells what the nurse is going

to do (e.g., “assist” or “supervise”).3. A prescribed activity (e.g., ambulation).

4. Specific time units (e.g., for 15 minutes at least fourtimes a day).

5. Signature of the nurse who writes the initial action order(i.e., accepting legal and ethical accountability).

A nursing action should not be implemented unless allfive components are present. A nurse would not administera medication if the physician order read, “Give Demerol”;neither should a nurse be expected to implement a nursingaction that reads, “Increase ambulation gradually.”

Additional criteria that should be remembered toensure complete, safe, quality nursing action include:

1. Consistency between the prescribed actions, the nursingdiagnosis, and expected outcome (including numbering).

E X A M P L E

Nursing Diagnosis 1Impaired physical mobility, level 2.

Expected Outcome 1Will ambulate length of hall by 11/8.

Nursing Action 1

11/21. a. Prior to activity, assess BP, P, and R. Afteractivity assess: (1) BP, P, R; (2)presence/absence of vertigo; (3) circulation;(4) presence/absence of pain.

b. Assist to dangle on bedside for 15 minutes atleast 4 times a day on 11/2.

c. If BP, P, or R changes significantly or vertigo ispresent or circulation is impaired or pain ispresent, return to supine position immediately.Elevate head of bed 30 degrees for 1 hour; then45 degrees for 1 hour; then 90 degrees for 1hour. If tolerated with no untoward signs orsymptoms, initiate action 1b again.

d. Assist up to chair at bedside for 30 minutes atleast 4 times a day on 11/3.

e. Assist to ambulate to bathroom and back atleast 4 times a day on 11/4.

f. Supervise ambulation of one-half length of hallat least 4 times a day on 11/5 and 11/6.

g. Supervise ambulation of length of hall at least4 times a day on 11/7.S. J. Smith, RN

2. Consideration of both patient and facility resources. Itwould be senseless to make referrals to physical andoccupational therapy services if these were not available.Likewise, from the patient’s resource viewpoint, itwould be foolish to teach a patient and his or her familyhow to manage care in a hospital bed if this bed wouldnot be available to the patient at home.

3. Careful scheduling to include the patient’s significantothers and to incorporate usual activities of daily living(i.e., rest, meals, sleep, and recreation).

4. Incorporation of patient teaching and discharge planningfrom the first day of care.

10 Introduction

••••••


?

5. Individualization and updating in keeping with thepatient’s condition and progress.

Including the key components and validating the qual-ity of the written nursing actions help promote improveddocumentation. In essence, the written nursing actions cangive an outline for documentation.

Properly written nursing actions demonstrate to thenurse both nursing actions and documentation to be done.Referring to the preceding example, we can see that thenurse responsible for this patient’s care should chart thepatient’s blood pressure (BP), pulse (P), and respiration (R)rates prior to the activity, the patient’s BP, P, and R ratesafter the activity, the presence or absence of vertigo, thepresence or absence of pain, and the results of a circulatorycheck. Additionally, the nurse knows to chart that the patientdangled, sat up, or ambulated for a certain length of time ordistance. Further, the nurse has guidelines of what to do andchart if an untoward reaction occurs in initial attempts atambulation.

E X A M P L E

1000 BP 132/82, P 74, R 16. Up on side of bed for 5minutes. Complained of vertigo and nausea.Returned to supine position with head of bed ele-vated to 30-degree angle. BP 100/68, P 80, R 24.

1100 BP 122/74, P 76, R 18. No complaints of vertigoor nausea. Head of bed elevated to 45-degreeangle.

Writing nursing actions in such a manner automati-cally leads to reflection of the quality of care planning in thechart. Documentation of care planning in the patient’s chartis essential to meet national standards of care and criteria foragency accreditation.

DOCUMENTATION

Just as development of the nursing process as a frameworkfor practice has evolved, so documentation of that processhas become an essential link between the provision of nurs-ing care and the quality of the care provided. Several nurs-ing documentation systems, both paper and electronic, haveemerged that make it easier to document the nursing pro-cess. Four of these systems are discussed here. You will notethat the narrative system is not discussed, because it tends tobe fragmented and disjointed and presents problems inretrieval of pertinent information about the patient responseto, and outcomes of, nursing care.

The Problem-Oriented Record (POR) with its for-mat for documenting progress notes provides a system fordocumenting the nursing process. Additionally, POR is aninterdisciplinary documentation system that can be used tocoordinate care for all health-care providers working withthe patient.

The POR consists of four major components:

1. The database2. The problem list

3. The plan of care4. The progress notes

The database is that information that has been col-lected through patient interview, observation, and physicalassessment and the results of diagnostic tests. The databaseprovides the basis for developing the problem list.

The problem list is an inventory of numbered, priori-tized patient problems. Patient problems may be written asnursing or medical diagnoses. Problems may be actual orrisk diagnoses. Because each problem is numbered, infor-mation about each problem is easily retrieved.

The plan of care incorporates the expected outcomes,target dates, and prescribed nursing actions as well as otherinterventions designed to resolve the problem. The plan ofcare reflects multidisciplinary care and should be agreed toby the health-care team.

The progress note provides information about thepatient’s response to or outcomes of the care provided.The full format for documenting progress is based on theacronym SOAPIER, which stands for Subjective data,Objective data, Analysis/assessment, Plan, Intervention,Evaluation, and Revision. As the plan of care is imple-mented for each numbered, prioritized problem, it is docu-mented using the SOAPIER format. For example, recall thecase of Mr. Kit, the 19-year-old college student who isrecovering from an appendectomy. The problem list inven-tory would probably show Problem #1: Pain. His plan ofcare would state as an expected outcome: “Uses oral anal-gesic relief measures by [date]” and “Will have discontinueduse of PCA and will request oral pain medication as neededfor analgesia by 11/3.”

Some of the written nursing actions would read:

1. Monitor for pain at least every 2 hours and have patientrank pain on a scale of 0–10.

2. Administer pain medications as ordered. Monitorresponse.

3. Spend at least 30 minutes once a shift teaching patientdeep muscle relaxation. Talk patient through relaxationevery 4 hours, while awake, at [list times here] once ini-tial teaching is done.

The progress note of 11/3 would appear as follows:

Problem 1–Progress Note

S “I have had only one pain medication during thelast 24 hours, and that relieved my pain.” “Iwould rank my pain as a 1 on a scale of 0–10.”

O Relaxation exercises taught, and return-demonstration completed on 11/2. No requestfor pain medication within past 12 hours.

A Pain relieved.P None.I None.E Expected outcome met. Problem resolved.

Discontinue problem.R None.


••••••


The POR with its SOAPIER progress note emphasizesthe problem-solving component within the nursing processand provides documentation of the care provided. For fur-ther information about the POR system, you are directed tothe Weed17 reference.

FOCUS charting, which is actually an offshoot ofPOR, is a documentation system that uses the nursingprocess to document care. Unlike the interdisciplinaryPOR, FOCUS charting is entirely oriented to nursing docu-mentation. Like the POR system, FOCUS charting has a

database, a problem list (FOCUS), a plan of care, andprogress notes. However, the FOCUS (problem list) isbroader than POR. In addition to nursing and medical diag-noses, the FOCUS of care may also be treatments, proce-dures, incidents, patient concerns, changes in condition, orother significant events. The medical record incorporatesthe plan of care in a three-column format (in additionto date/signature) labeled “FOCUS,” “expected patient out-comes,” and “nursing interventions.” To illustrate, againwith Mr. Kit:

12 Introduction

••••••

DATE/SIGNATURE FOCUS EXPECTED PATIENT OUTCOME NURSING INTERVENTION

11/1J. Jones, RN

Will progress to 4 or morehours between requestsfor analgesics by 11/3.

Monitor for pain at least every 2 hours. Have pt ratepain on 0–10 scale.

Administer pain med as ordered. Monitor response.Spend at least 30 minutes once a shift teaching

patient deep muscle relaxation. Talk patient throughrelaxation every 4 hours, while awake, at [list timeshere] once initial teaching is done.

Pain

DATE/TIME SIGNATURE FOCUS PATIENT CARE NOTE

11/1 1500 J. Jones, RN

11/1 1530 J. Jones, RN

11/1 1615 J. Jones, RN

Pain D C/o pain, “My side hurts. It is a 9 on a 0–10 scale.” BP 130/84, P 88, R 22.

A Demerol 100 mg given in rt gluteus. Turned to left side. Back rub given.

R States pain is better. Rates it 2 on a 0–10 scale. BP 120/80, P 82, R 18.

The progress notes incorporate a flow sheet for docu-menting daily interventions and treatments and a narrativeprogress note using a three-column format. The three-columnformat for the progress note includes a column for date, time,

and signature; a FOCUS column; and a patient care note col-umn. When the progress note is written in the patient carenote column, it is organized using the acronym DAR—Data,Action, and Response. To illustrate, again using Mr. Kit:

DATE TIME NURSE’S NOTES

11/1

11/1

11/1

1500

1530

1615

P#1 Pain.IP#1 BP 130/84, P 88, R 22.

J. Jones, RN

IP#1 Demerol 100 mg given IM in rtgluteus. Turned to left side. Backrub given. J. Jones, RN

EP#1 States pain relieved. Ratespain as 2 on a 0–10 scale. BP120/80, P 82, R 18. J. Jones, RN

FOCUS charting provides a succinct system for docu-menting the nursing process. It reflects all the elementsrequired by JCAHO. It is flexible, provides cues to docu-mentation with its DAR format, and makes it easy to retrievepertinent data. For more information on FOCUS, use theinformation written by Lampe.26

The PIE documentation system emphasizes the nurs-ing process and nursing diagnosis. PIE is the acronym forProblem, Intervention, and Evaluation. A timesaving aspectof this system is that PIE does not require a separate plan ofcare. The initial database and ongoing assessments arerecorded on special forms or flow sheets. Assessment dataare not included in the progress note unless a change in thepatient’s condition occurs. If a change occurs, “A” forassessment would be recorded in the progress note. Routineinterventions are recorded on a flow sheet, and the progressnote is used for specific numbered problems.

When a problem is identified, it is entered into theprogress note as a nursing diagnosis. Each problem is num-bered consecutively during a 24-hour period, for example,P#1 and P#2. Therefore, the nurse may refer to the number

rather than having to restate the problem. Interventions (I),directed to the problem are documented relative to the prob-lem number (e.g., IP#1 or IP#2). Evaluation (E) reflectspatient response to or outcomes of nursing intervention andis labeled according to the problem number (e.g., EP#1 orEP#2). To illustrate, again using Mr. Kit:


Each problem is evaluated at least every 8 hours, andall problems are reviewed and summarized every 24 hours.Continuing problems with appropriate interventions andevaluation are renumbered and redocumented daily, thuspromoting continuity of care. When a problem is resolved, itno longer is documented.

The PIE documentation system reflects the nursingprocess and simplifies documentation by integrating theplan of care into the progress notes. This saves time and pro-motes easy retrieval of pertinent data. Siegrist, Deltor, andStocks27 are the originators of the PIE system.

Charting by Exception was developed by nurses atSaint Luke’s Hospital in Milwaukee, Wisconsin.28 Docu-menting in this system differs significantly from traditionalsystems in that nurses chart only significant findings orexceptions to a predetermined norm.

This system centers on the development of clinicalstandards that describe accepted norms. The system makesextensive use of flow sheets and is becoming increasinglypopular because of its streamlined format and cost-effec-tiveness.

A patient care plan is established based on describedstandards. Nursing actions are used as the base for docu-mentation. Flow sheets are used to highlight significant find-ings and define assessment parameters and findings. Forexample, for the postpartum patient, the standard for thecardiovascular assessment is:

Cardiovascular assessment: Apical pulse, CRT, periph-eral pulses, edema, calf tenderness.

Standard: Regular apical pulse, CRT �3 s, peripheralpulses palpable, no edema, no calf tenderness, nail bedsand mucous membranes pink.

If the assessment findings were the same as the stan-dard, the nurse simply makes a check mark on the flow sheetby cardiovascular assessment. If the assessment findings aredifferent from the standard, the nurse marks an asterisk bycardiovascular assessment and explains the deviation fromthe standard in the narrative notes.

Charting by Exception has been shown to reduce doc-umentation time and costs and increase attention to abnor-mal data. In addition, documentation is more consistent.More information about this system and examples of flowcharts can be found in the publication Charting byException.28

To complete the nursing process cycle and, dependingon its outcome, perhaps start another cycle, the final phaseof the process—evaluation—must be done.

EVALUATION

Evaluation simply means assessing what progress has beenmade toward meeting the expected outcomes; it is the mostignored phase of the nursing process. The evaluation phaseis the feedback and control part of the nursing process.Evaluation requires continuation of assessment that wasbegun in the initial assessment phase. In this instance,

assessment is the data collection form we use to measurepatient progress.

Data CollectionInitially, specific data should be collected to measure theprogress made toward achieving the stated expected out-come. As an example, let us return to the outcome writtenfor Mr. Kit, the 19-year-old college student who had anappendectomy. The expected outcome was “Will have dis-continued use of PCA and will request oral pain medicationas needed for analgesia by 11/3.” It is now 11/3, and thenurse caring for Mr. Kit notes the date and initiates evalua-tion of the outcome. She first checks the chart and counts thenumber of complaints of pain, number and types of anal-gesics given, and Mr. Kit’s response to the pain medication.She looks for any change in medication or a change in Mr.Kit’s condition. She then interviews Mr. Kit regarding hisperception of pain acuity and level of relief. At the sametime, the nurse completes other assessments, such as observ-ing the wound condition and the ease of ambulation ornoting the presence of any other untoward signs or symp-toms. The nurse then studies the data to see what action isnecessary.

Action Following Data CollectionAction following data collection simply means making anursing judgment of what modifications in the plan of careare needed. There are essentially only three judgments thatcan be made:

1. Resolved2. Revise3. Continue

Resolved means that the evaluative data indicate thehealth-care problem reflected in the nursing diagnosis andits accompanying expected outcome no longer exist; that is,the expected outcome has been met. The nurse documentsthe data collected and records the judgment—“Resolved.”To illustrate, let us return to Mr. Kit.

First, the nurse reviews the chart. She finds that Mr.Kit requested pain medication every three to four hours forthe first 18 hours after surgery. The nurses taught Mr. Kitrelaxation exercises and turned him, positioned him, andgave him a back rub immediately after the administration ofeach analgesic. Mr. Kit has requested only one analgesic inthe past 24 hours and none in the past 12 hours. He canreturn-demonstrate relaxation exercises and states he hasonly a mild “twinge” when he gets out of bed. He is lookingforward to returning to school next week.

The nurse returns to the patient’s chart and records thefollowing: “11/3 Data—1 oral analgesic in past 24 hours;none in past 12 hours. Ambulates without pain; states hav-ing no pain. Resolved.” She then will draw one line throughthe nursing diagnosis, related expected outcome(s), andnursing actions to show they have been discontinued.

Revise can indicate two actions. In one instance, theinitial nursing diagnosis was not correct, so the diagnosisitself is revised. For example, the nurse may have made an


••••••


initial diagnosis of Self-Esteem Disturbance. During col-lection of evaluation data, the patient and his family sharefurther information that indicates that the more appropriatediagnosis is Powerlessness, Moderate. The plan of careis then modified to reflect the change in the nursing diagno-sis. For evaluation purposes, the nurse again records the dataand the word, “Revised.” She then adds the new nursingdiagnosis and marks one line through the initial nursingdiagnosis.

In the second instance, while the nurse is collectingevaluation data for one nursing diagnosis and expected out-come, she finds assessment factors that show another prob-lem has arisen. She simply records the appropriate judgmentfor the initial diagnosis and expected outcome (e.g.,“Resolved”) and revises the plan to include the new nursingdiagnosis with its appropriate expected outcome and nursingactions.

Continue indicates that the expected outcome has notbeen met. The nurse again collects the appropriate data and,based on the data, makes the nursing judgment that theexpected outcome has not been met. She records the dataand adds the phrase, “Continue, reevaluate on [date].” Shethen modifies the plan of care by going back to the statedexpected outcome, marking one line through the date, andadding a new date. Likewise, the nursing actions would bemodified as necessary.

With evaluation, the nursing process cycle is com-pleted (Fig. 1.1). Another cycle can begin with both thenurse and the patient insuring that quality care is being givenand received. To assist you with the evaluation process, wehave provided an evaluation flowchart template (Fig. 1.2).You can use this format to evaluate any nursing diagnosis bycompleting the chart with your specific information.

Building Conceptual Understandingswith Care PlansCare plans, in the format of concept maps, have emerged asan innovative teaching tool.29,30 This format will help you, asa student, to understand the links between assessment andcare, build clinical decision-making skills by increasingunderstanding of information relationships, and link theoryto practice. Concept maps also assist with the developmentof critical thinking skills.29,31-33

The concept map care plan begins with the client’sreasons for seeking health care. Branching from this are therelated nursing diagnoses with the supporting data. Linksthat designate the relationships between the diagnoses andreasons for seeking care are developed. Links between thediagnoses show their relationships.34 This information isthen transferred to a problem or diagnosis work sheet, andthe goals and interventions are developed followed by anevaluation of the client response.29 A sample concept mapfor Mr. Kit is provided for you in Fig. 1.3. You can find fur-ther information on concept mapping in Concept Mapping:A Critical-Thinking Approach to Care Planning.29 Whenyou are developing a concept map you may find a programsuch as Inspiration® a helpful development tool. This pro-

gram will assist you in developing concept boxes and link-ing the arrows. Some schools of nursing provide thisresource for their students. You can also find this tool on theprogram’s Web site (http://www.inspiration.com).

NURSING PROCESS ANDCONCEPTUAL FRAMEWORKS

NURSING MODELS

Many nurses do not see a direct relationship between nurs-ing models (nursing theories) and nursing process, but adirect relationship does exist. Nursing models present a sys-tematic method for assessing and directing nursing practicethrough promoting organization and integration of what isknown about human health, illness, and nursing. The nurs-ing process is the action phase of a nursing model. Kataoka-Yahiro and Saylor35 indicate that the nursing process is amethod of problem solving and decision making and can beseen as a discipline specific method for critical thinking. Inessence, models guide the use of the nursing process,36 and,as previously stated, the care planning presented in this bookis a result of the nursing process.

For further clarification, let us look at a few examples.If you are a supporter of Levine’s Conservation Model, youwould assess your patient in keeping with this model andthen design your care plan to reflect prioritizing of the nurs-ing diagnoses and nursing actions in a manner that wouldbest promote conservation principles. Likewise, if you are aproponent of Roy’s Adaptation Model, you would assess thefour adaptation modes, and then prioritize your diagnosesin an order that would best promote adaptive responses. Insummation, current nursing models affect care planning interms of assessment and prioritizing of nursing diagnosesrather than requiring different diagnostic statements and dif-ferent nursing actions.

PATTERNS

Several typologies have emerged as a result of the workdone with nursing diagnosis. The typologies are representa-tive of another step in theory development and are designedto facilitate the use of nursing diagnosis. The typologies pro-vide an organizational framework that enables the nurse tofocus on the pattern description and assessment rather thantrying to remember all the details of individual diagnoses.The nurse can easily locate the individual diagnoses bybeing familiar with the patterns.

Functional Health PatternsGordon7 writes that the Functional Health Patterns wereidentified, circa 1974, to assist in the teaching of assessmentand diagnosis at Boston College School of Nursing. TheFunctional Health Patterns organize the individual diag-noses into categories, thus providing for the organized col-lection of assessment data.

The advantages offered by assessment according to theFunctional Health Patterns include having a standardized

14 Introduction

••••••


Nursing Process and Conceptual Frameworks 15

••••••

Has the goal been achieved?

No

Yes

Reassess using initial assessment factors

Is diagnosis validated?No

Record new assessment data.Record REVISE. Add newdiagnosis, expected outcome,target date, and nursing actions.Delete invalidated diagnosis.

Start new evaluation process

No Finished

Did evaluation show anotherproblem had arisen?

Record data, e.g., assessmentshows continued fluctuationin energy field. RecordCONTINUE and changetarget date. Modify nursingactions as necessary.

Yes

Yes

Record data, e.g., record assessment data.Record RESOLVED. Delete nursingdiagnosis, expected outcome, target date,and nursing actions.

F I G U R E 1 . 2 Flowchart evaluation: Expected outcome. (From Cox, HC, Hinz, MD,Lubno, MA, Scott-Tilley, D, Newfield, SA, Slater, M, and Sridaromont, KL: ClinicalApplications of Nursing Diagnoses: Adult, Child, Women’s, Psychiatric, Gerontic, andHome Health Considerations, ed 4. FA Davis, Philadelphia, 2002.)

method that does not have to be relearned if the setting,patient’s age, or condition changes; having an assessmenttool specifically designed to lead to identification of perti-nent nursing diagnoses; and having an assessment methodthat is holistic in nature.37

Functional Health Patterns focus on the client’s usualways of living37 and direct attention to all the factors thatimpact the individual in these ways of living. Gordon7

defines a pattern as “a sequence of behavior across time.”The Functional Health Patterns allow the nurse to assess

these behaviors by promoting the patient’s describing hisor her own perception as well as incorporating thenurse’s observations. Both the patient’s description and thenurse’s observations must be included to ensure a completeassessment.

Use of the Functional Health Patterns for assessmentallows identification of three major types of data:

1. Functional patterns: The functional patterns are clientstrengths that can be used to deal with either dysfunc-


tional or potentially dysfunctional patterns; for example,Assessment of the Coping–Stress Tolerance Patternshows no problem areas. The nurse can then use thisfunctional pattern to assist the patient in learning to copewith the identified problem areas.

2. Dysfunctional patterns: The Dysfunctional HealthPatterns identify problem areas and the nursing diag-noses related to each problem area; for example, inassessing the Elimination Pattern, the nurse identifiedproblems with urination and specifically with UrinaryRetention. Knowing that the patient has effective indi-vidual coping, the nurse then plans teaching that willutilize this strength rather than interventions that aretotally nursing focused such as intermittent catheteriza-tion. The nurse could teach the patient to use Credé’smaneuver, pouring warm water over the genital area,running tap water, and so on to use the client’s alreadydemonstrated strength.

3. Potential dysfunctional patterns: The PotentialDysfunctional Patterns are risk conditions; for example,a client who has urinary retention is at risk for the devel-opment of Excess Fluid Volume. Utilizing this knowl-edge, the nurse would identify areas of observation tomonitor and to teach the patient to monitor.

Use of the Functional Health Patterns in assessmentstresses focus on a nursing model of assessment, diagnosis,planning, intervention, and evaluation rather than a medical

model. Thus, the nurse can readily differentiate betweenareas for independent nursing intervention and areas requir-ing collaboration or referral.

Table 1.3 lists the Functional Health Patterns alongwith a brief description of each pattern as designed byGordon.37 The titles of the patterns are, in essence, self-explanatory. Because the titles are self-explanatory, theFunctional Health Patterns are easy to use. The chapters inthis book are organized using the Functional Health Patternsand each chapter includes more detail regarding each func-tional health pattern as introductory information for the spe-cific chapter.

Human Response PatternsPatterns of Unitary Persons were first presented at the FourthNational Conference of NANDA. A group of nursing theo-rists met in between, as well as during, conferences to designa framework for classification of nursing diagnoses.38,39 TheNANDA Taxonomy Committee and Special Interest Groupon Taxonomy40 reviewed, clarified, and relabeled the pat-terns as Human Response Patterns. These revisions werepresented at the Fifth and Sixth National Conferences. Thepatterns proposed by the theorist group describe clusteringfactors that represent person-environment interaction.41 TheUnitary Persons categories were not mutually exclusive; thatis, one nursing diagnosis might relate to one, two, or eventhree of the patterns. From the Fifth through the NinthNational Conferences, refinement of the Human Response

16 Introduction

••••••

Reason for needing health care Appendectomy

Key assessment: pain, VS, dressings

AnxietyVerbalization of anxietyBP 130/84, P88, R22difficulty concentrating

expresses fearof unknown

Acute painSurgical wound

Rates pain as 7 on 10-point scale

BP 130/84, P88, R22

Readiness for enhancedknowledge

Indicates this is firsthospitalization

Frequently asks questions RTself-care

Impaired skin integritySurgical wound

less than 24 hours old

Induces

Indu

ces

Induces

Decreases/Effects

Enhances

Effects

Induces

Induces

F I G U R E 1 . 3 Concept map.


Patterns has continued. At the Seventh National Conferencethe Human Response Patterns were presented as the frame-work for NANDA Nursing Diagnosis Taxonomy I,42 and thetaxonomy was endorsed by NANDA members attending thisconference. To assist in applying this typology, each diagno-sis has information regarding its category and coding placein the Human Response Pattern.

This endorsement indicated acceptance of the Taxon-omy I as a working document that would require furthertesting, revision, refinement, and expansion. Additionalinput regarding Taxonomy I Revised was solicited at theEighth National Conference. Much of the discussion atthe Eighth Conference focused on the various levels of thetaxonomy with specific questions of the clinical usefulnessof level I.

The first level of abstraction in Taxonomy I is theHuman Response Patterns. The second level is alterations infunctions. Levels II through V become increasingly con-crete, with levels IV and V reflecting the diagnostic labels.Table 1.4 lists the Human Response Patterns with accompa-nying brief definitions. In this book we have focused on levelII and include levels IV and V in the conceptual informationand “Have You Selected the Correct Diagnosis?” sections.

Diagnostic Divisions: Taxonomy IIFollowing the Twelfth NANDA Conference, the TaxonomyCommittee initiated work on Taxonomy II. NANDA mem-bers had expressed concerns regarding the ease of use ofTaxonomy I Revised and the unclear classification of diag-noses into the taxonomic patterns.

After reviewing multiple taxonomic structures, theTaxonomy Committee voted to use an adaptation ofMarjorie Gordon’s Functional Health Patterns (FHP) as thebasic taxonomic structure for Taxonomy II. The TaxonomyCommittee received permission from Dr. Gordon and herpublishers to adapt and use the FHP. Table 1.5 demonstratesthis new structure.

At the Thirteenth Conference, the proposed TaxonomyII was presented for members’ review and discussion.Additionally, members attending the conference participatedin a Q-sort project. This project requested the participants tosort the individual nursing diagnoses into the proposedclasses and served to validate diagnosis placement.

Subsequent to the Thirteenth Conference, the Taxon-omy Committee continued to work on the refinement ofTaxonomy II. At the Fourteenth Conference held in April2000, Taxonomy II was presented to the NANDA mem-

Nursing Process And Conceptual Frameworks 17

••••••

T A B L E 1 . 3 Functional Health Patterns

PATTERN DESCRIPTION

Health Perception–Health Management

Nutritional–Metabolic

Elimination

Activity–Exercise

Sleep–Rest

Cognitive–PerceptualSelf-Perception and Self-ConceptRole–Relationship

Sexuality–Reproductive

Coping–Stress Tolerance

Value–Belief

Source: From Gordon, M: Manual of Nursing Diagnosis. Tenth edition, 2002. CV Mosby, St. Louis,pp 2–5, with permission.

The client’s perceived pattern of health and well-being and how health ismanaged.

Describes pattern of food and fluid consumption relative to metabolicneed and pattern indicators of local nutrient supply.

Describes pattern of excretory function (bowel, bladder, and skin). Alsoincluded are any devices used to control excretion.

Describes pattern of exercise, activity, leisure, and recreation. Includesactivities of daily living, requiring energy expenditure. Emphasis is onthe activities of high importance or significance and any limitations.

Describes patterns of sleep, rest and relaxation periods during the 24-hour day. Includes client’s perception of the quantity and quality ofsleep and rest.

Describes sensory-perceptual and cognitive pattern.Describes self-concept pattern and perceptions of mood state.Describes patterns of role engagement and relationships. Includes the

individual’s perception of the major roles and responsibilities of thecurrent life situation.

Describes patterns of satisfaction-dissatisfaction with sexuality. Describesreproductive pattern.

General coping pattern and the effectiveness of the pattern in terms ofstress tolerance.

Describes patterns of values, goals, or beliefs (including spiritual) thatguide choices or decisions. Includes what is perceived as important tolife, quality of life, and any perceived conflicts in values, beliefs, orexpectations that are health related.


18 Introduction

••••••

T A B L E 1 . 4 Human Response Patterns

PATTERN DESCRIPTION

Exchanging

Communicating

Relating

Valuing

Choosing

Moving

Perceiving

Knowing

Feeling

Source: From Fitzpatrick, JJ: Taxonomy II: Definitions and development. In Carroll-Johnson, RM (ed):Classification of Nursing Diagnosis: Proceedings of the Ninth Conference. Lippincott, Philadelphia,1991, with permission.

To give, relinquish, or lose something while receiving something in return; the substitutionof one element for another; the reciprocal act of giving and receiving

To converse; to impart, confer, or transmit thoughts, feelings, or information, internally orexternally, verbally or nonverbally

To connect, to establish a link between, to stand in some association to another thing,person, or place; to be borne or thrust in between things

To be concerned about, to care; the worth or worthiness; the relative status of a thing, orthe estimate in which it is held, according to its real or supposed worth, usefulness, orimportance; one’s opinion of like for a person or thing; to equate in importance

To select between alternatives; the action of selecting or exercising preference in regardto a matter in which one is a free agent; to determine in favor of a course; to decide inaccordance with inclinations

To change the place or position of a body or any member of the body; to put and/or keepin motion; to provoke an excretion or discharge; the urge to action or to do something;leave in; to take action

To apprehend with the mind; to become aware of by the senses; to apprehend what is notopen or present to observation; to take in fully or adequately

To recognize or acknowledge a thing or person; to be familiar with by experience orthrough information or report; to be cognizant of something through observation,inquiry, or information; to be conversant with a body of facts, principles, or methods ofaction; to understand

To experience a consciousness, sensation, apprehension, or sense; to be consciously oremotionally affected by a fact, event, or state

T A B L E 1 . 5 Taxonomy II: Domains and Classes

DOMAINS AND CLASSES DESCRIPTION

Domain 1

Class 1Class 2

Domain 2

Class 1Class 2

Class 3Class 4

Class 5

Domain 3

Class 1

Health Promotion: Diagnoses that refer to the awareness of well-being or normality offunction and the strategies used to maintain control of and enhance that well-beingor normality of function

Health Awareness: Recognition of normal function and well-beingHealth Management: Identifying, controlling, performing, and integrating activities to

maintain health and well-being

Nutrition: Diagnoses that refer to the activities of taking in, assimilating, and usingnutrients for the purposes of tissue maintenance, tissue repair, and the production ofenergy

Ingestion: Taking food or nutrients into the bodyDigestion: The physical and chemical activities that convert foodstuffs into substances

suitable for absorption and assimilationAbsorption: The act of taking up nutrients through body tissueMetabolism: The chemical and physical processes occurring in living organisms and

cells for the development and use of protoplasm, production of waste and energy,with the release of energy for all vital processes

Hydration: The taking in and absorption of fluids and electrolytes

Elimination/Exchange: Diagnoses that refer to secretion and excretion of wasteproducts from the body

Urinary System: The process of secretion and excretion of urine



••••••


Class 2Class 3Class 4

Domain 4

Class 1Class 2

Class 3

Class 4

Class 5

Domain 5


Class 4

Class 5

Domain 6Class 1Class 2Class 3

Domain 7

Class 1

Class 2

Class 3

Domain 8Class 1Class 2Class 3

Domain 9


Domain 10

Class 1Class 2

Class 3

Gastrointestinal System: Excretion and expulsion of waste products from the bowelIntegumentary System: Process of secretions and excretion through the skinPulmonary System: Removal of byproducts of metabolic products, secretions, and

foreign material from the lung or bronchi

Activity/Rest: Diagnoses that refer to the production, conservation, expenditure, orbalance of energy resources

Sleep/Rest: Slumber, repose, ease, or inactivityActivity/Exercise: Moving parts of the body (mobility), doing work, or performing actions

often (but not always) against resistanceEnergy Balance: A dynamic state of harmony between intake and expenditure of

resourcesCardiovascular/Pulmonary Responses: Cardiopulmonary mechanisms that support

activity/restSelf Care: Ability to perform activities to care for one’s body and bodily functions.

Perception/Cognition: Diagnoses that refer to the human information processing system,including attention, orientation, sensation, perception, cognition, and communication

Attention: Mental readiness to notice or observeOrientation: Awareness of time, place, and personSensation/Perception: Receiving information through the senses of touch, taste, smell,

vision, hearing, and kinesthesia and the comprehension of sense data resulting innaming, associating, and/or pattern recognition

Cognition: Use of memory, learning, thinking, problem solving, abstraction, judgment,insight, intellectual capacity, calculation, and language

Communication: Sending and receiving verbal and nonverbal information

Self-Perception: Diagnoses that refer to awareness about selfSelf-Concept: Perception(s) about the total selfSelf-Esteem: Assessment of one’s own worth, capability, significance, and successBody Image: A mental image of one’s own body

Role Relationships: Diagnoses that refer to the positive and negative connections orassociations between persons or groups of persons and the means by which thoseconnections are demonstrated

Caregiving Roles: Socially expected behavior patterns by persons providing care who arenot health-care professionals

Family Relationships: Associations of people who are biologically related or related bychoice

Role Performance: Quality of functioning in socially expected behavior patterns

Sexuality: Diagnoses that refer to sexual identity, sexual function, and reproductionSexual Identity: The state of being a specific person in regard to sexuality and/or genderSexual Function: The capacity or ability to participate in sexual activitiesReproduction: Any process by which new individuals (people) are produced

Coping/Stress Tolerance: Diagnoses that refer to the contending with life events/lifeprocesses

Post-Trauma Responses: Reactions occurring after physical or psychological traumaCoping Responses: The process of managing environmental stressNeurobehavioral Stress: Behavioral responses reflecting nerve and brain function

Life Principles: Diagnoses that refer to principles underlying conduct, thought and behaviorabout acts, customs, or institutions viewed as being true or having intrinsic worth

Values: The identification and ranking of preferred modes of conduct or end statesBeliefs: Opinions, expectations, or judgments about acts, customs, or institutions viewed

as being true or having intrinsic worthValue/Belief/Action Congruence: The correspondence or balance achieved between

values, beliefs, and actions(table continued on page 20)


20 Introduction

••••••

T A B L E 1 . 5 Taxonomy II: Domains and Classes (continued from page 19)


Domain 11

Class 1Class 2Class 3Class 4Class 5Class 6

Domain 12


Domain 13

Class 1Class 2

Domain 14

Source: From North American Nursing Diagnosis Association: NANDA Nursing Diagnoses: Definitionsand Classification 2005–2006. NANDA-I, Philadelphia, 2005, with permission.

Safety/Protection: Diagnoses that refer to freedom from danger, physical injury orimmune system damage, preservation from loss, and protection of safety and security

Infection: Host responses following pathogenic invasionPhysical Injury: Bodily harm or hurtViolence: The exertion of excessive force or power so as to cause injury or abuseEnvironmental Hazards: Sources of danger in the surroundingsDefensive Processes: The processes by which the self protects itself from the nonselfThermoregulation: The physiologic process of regulating heat and energy within the

body for purposes of protecting the organism

Comfort: Diagnoses that refer to the sense of mental, physical, or social well-being orease

Physical Comfort: Sense of well-being or easeEnvironmental Comfort: Sense of well-being or ease in/with one’s environmentSocial Comfort: Sense of well-being or ease with one’s social situations

Growth/Development: Diagnoses that refer to age-appropriate increases in physicaldimensions, organ systems, and/or attainment of developmental milestones

Growth: Increases in physical dimensions or maturity of organ systemsDevelopment: Attainment, lack of attainment, or loss of developmental milestones

Other: Diagnoses that are unclassifiable until new categories or classes are developed orold ones are redefined

bership for further consideration. The NANDA Board ofDirectors approved Taxonomy II following the FourteenthConference and additional revision by the TaxonomyCommittee.

A unique feature of Taxonomy II is the use of axes.The use of axes simplifies wording structure of the diag-noses, allows a broader use of diagnostic terminology, ismore clinically expressive, and promotes inclusion of nurs-ing diagnoses into computerized databases. The proposedaxes are illustrated in Table 1.6.

To illustrate the use of the multiaxial structure, thisexample is provided. A client is assessed at a clinic. Theclient is a 15-year-old who is 5 ft 2 in tall and weighs 190 lb.The nurse decides the applicable diagnostic concept (Axis 1)is Nutrition. She then chooses a modifier from Axis 6—“Altered” and “More than Body Requirements.” The nursedoes not add “Adolescent” from the Development Stage Axis(Axis 4) because further assessment documents that theclient’s entire family (brother, mother, and father) are alsoabove standard weights for their age and height. Therefore,she selects “Family” from Axis 3 (Unit of Care). Because theproblem is currently present, the nurse selects “Actual” fromthe Potentiality Axis (Axis 5). The diagnostic statement thenbecomes: Actual Altered Nutrition, More than BodyRequirements by a Family. Stating the diagnostic statementin this fashion promotes intervention for the whole family,

which, in turn, increases the probability of successful inter-vention for the individual patient.

Additional Taxonomy DevelopmentWith the ongoing development of language to describe thewhole of nursing practice, NANDA, NIC, and NOC havedeveloped taxonomies to organize their concepts, includinghuman responses, nursing interventions, and nursing out-comes. Since each of these taxonomies represent stages ofthe nursing process, it is only logical that they be linkedto assist the practitioner in the process of care plan devel-opment. To facilitate this linking, the NNN Allianceof NANDA-I, NIC, and NOC developed NNN Taxonomy ofNursing Practice. This taxonomy has blended features ofeach of the parent taxonomies. There are four Domains and28 Classes3 (see Table 1.7). In this edition, the authors of thisbook have provided tables that demonstrate the suggestedlinkages between NANDA-I,3 NIC,4 and NOC.5 It is impor-tant to remember that these linkages are only suggested byNNN, and that the ultimate decisions related to diagnosis,intervention, and outcome area are those of the practitionerswho are responsible for providing safe, effective, individual-ized care to their client systems. Our decision to present thelinkages in a chart form, rather than listing the taxonomydesignations, was based on the evolving nature of nursingtaxonomies and a desire to provide this information to you in


a manner that was easily accessible to the care planningprocess. These tables can be found at the end of the concep-tual information in each chapter.

To demonstrate the use of the various taxonomies theyoung man discussed above will be utilized. As you discov-ered previously his nursing diagnosis, according to NANDATaxonomy II would be:

Domain 2 NutritionClass 1 Ingestion

00001 Imbalanced nutrition: More than body requirementsThe axes would then be added to increase the

specificity of the diagnosis.The NIC interventions, according to the NIC taxon-

omy for this NANDA diagnosis would be:Domain I Functional Domain

Class 2 NutritionInterventions:1100: Nutrition Management1260: Weight Management1280: Weight Reduction Assistance

The NOC outcomes measures from the NOC taxon-omy would be:

Domain II Physiologic HealthClass K Nutrition

Level 3: 1004: Nutritional Status1006: Nutritional Status: Body Mass1008: Nutritional Status: Food &Fluid Intake

Domain IV Health Knowledge & BehaviorClass Q Health Behavior

Level 3: 1612: Weight ControlWithin the NNN Taxonomy for Nursing Practice the

label would be:Domain I Functional

Class NutritionAs demonstrated in this example, the flow of care

planning across the Taxonomies can be quite cumbersome.Each of the three primary coding systems place related con-cepts in different categories. The Taxonomy for Nursing


••••••

T A B L E 1 . 6 Taxonomic Axes

Axis 1

Axis 2

Axis 3

Axis 4

Axis 5

Axis 6

Axis 7

Source: From North American Nursing Diagnosis Association:NANDA Nursing Diagnoses: Definitions and Classification2005–2006. NANDA-I, Philadelphia, 2005, with permission.

Diagnostic Concept: The nursingdiagnosis

Time: Acute, Chronic, Intermittent,Continuous

Subject of the Diagnosis: Individual,family, community, group

Age: Fetus to elder

Health Status: Wellness, Risk, Actual

Descriptor: A Judgment that limits orspecifies the meaning of a nursingdiagnosis. (e.g., Ability, Anticipatory,Balance, Compromised, Decreased,Deficient, Defensive, Delayed)

Topology: Parts/regions of the bodyand/or their related functions-alltissues, organs, anatomical sites orstructures (e.g., auditory, bowel,cardiopulmonary, gastrointestinal,intracranial, mucous membranes,olfactory, peripheral neurovascular,skin, visual)

T A B L E 1 . 7 NNN Taxonomy of Nursing Practice

Domain IClassClass

Class

ClassClassClassClassClass

Domain II

Functional: Includes diagnoses, outcomes, and interventions to promote basic needsActivity/Exercise: Physical activity, including energy conservation and expenditureComfort: A sense of emotional, physical, and spiritual well being and relative freedom for

distressGrowth and Development: Physical, emotional, and social growth and development

milestonesNutrition: Processes related to taking in, assimilating, and using nutrientsSelf-Care: Ability to accomplish basic and instrumental activities of daily livingSexuality: Maintenance or modification of sexual identity and patternsSleep/Rest: The quantity and quality of sleep, rest, and relaxation patternsValues/Beliefs: Ideas, goals, perceptions, spiritual and other beliefs that influence choices

or decisions

Physiological: Includes diagnoses, outcomes, and interventions to promote optimalbiophysical health

(table continued on page 22)


Practice is an attempt to resolve this issue and continues tobe developed. Currently, new work of NANDA-I, NIC, andNOC continues to be placed within their unique taxonomicsystems. The linking charts in each chapter will help youbegin integrating these powerful languages into your nurs-ing vocabulary and practice. To develop further expertise inthese nursing languages you are encouraged to review thepublications of NANDA-I,3 NIC,4 and NOC.5

VALUE PLANNING OFCARE AND CARE PLANS

The nursing process and the resultant plan for nursing carehave not been given the attention or credit that they deserve.Part of the problem is that planned nursing care has not hadvalue attached to it. All of us will make time or a place for

those things that are of value to us. It is only recently thatcompleting and evaluating the quality of care planning hasbegun to show up on employee evaluation forms. Likewise,it is still rare to see “complete nursing care plan” or “updatecare plan” on the patient assignment form.

With the changes that are occurring in health care, dueto federal and state legislated mandates, completion and useof nursing care planning is going to increase in importance.Several insurance companies now audit charts, care plans,and the like in detail. No documentation of care means noreimbursement for care. Likewise, one of the first places alawyer looks when hunting evidence for health-related courtcases is the patient’s chart. The basic principle in lawsuitshas been “not charted, not done.” Planning care as we pro-pose in this book would furnish additional documentationthat reasonably prudent care was given as well as providinga guideline for better charting.

22 Introduction

••••••

T A B L E 1 . 7 NNN Taxonomy of Nursing Practice (continued from page 21)

ClassClassClassClass

Class

Class

ClassClass

Class

Class

Domain III

ClassClass

ClassClassClass

Class

Class

Domain IV

Class

ClassClass

Source: From North American Nursing Diagnosis Association International: NANDA NursingDiagnoses: Definitions & Classification 2005–2006. NANDA International, Philadelphia, 2005.

Cardiac Function: Cardiac mechanisms used to maintain tissue profusionElimination: Processes related to secretion and excretion of body wastesFluid and Electrolytes: Regulation of fluid/electrolytes and acid base balanceNeurocognition: Mechanisms related to the nervous system and neurocognitive functioning,

including memory, thinking, and judgmentPharmacological Function: Effects (therapeutic and adverse) of medications or drugs and

other pharmacologically active productsPhysical Regulation: Body temperature, endocrine, and immune system responses to

regulate cellular processesReproduction: Processes related to human procreation and birthRespiratory Function: Ventilation adequate to maintain arterial blood gasses within normal

limitsSensation/Perception: Intake and interpretation of information through the senses,

including seeing, hearing, touching, tasting, smellingTissue Integrity: Skin and mucous membrane protection to support secretion, excretion,

and healing

Psychosocial: Includes diagnoses, outcomes, and interventions to promote optimal mentaland emotional health and social functioning

Behavior: Actions that promote, maintain, or restore healthCommunication: Receiving, interpreting, and expressing spoken, written, and nonverbal

messagesCoping: Adjusting or adapting to stressful eventsEmotional: A mental state or feeling that may influence perceptions of the worldKnowledge: Understanding and skill in applying information to promote, maintain, and

restore healthRoles/Relationships: Maintenance and/or modification of expected social behaviors and

emotional connectedness with othersSelf-Perception: Awareness of one’s body and personal identity

Environmental: Includes diagnoses, outcomes, and interventions to promote and protectthe environmental health and safety of individuals, systems, and communities

Health-Care System: Social, political, and economic structures and processes for thedelivery of healthcare services

Populations: Aggregates of individuals or communities having characteristics in commonRisk Management: Avoidance of identifiable health threats


Use of nursing diagnosis helps ensure that teachingand discharge planning are considered from the start of care.As we increase our knowledge and begin to think in termsrelated to nursing nomenclature, nursing actions for manyof the diagnoses will relate to teaching and planning forhome care.

Many of the standards supported by JCAHO, theANA, and state boards of nursing are automatically imple-mented when the nursing process is completed, imple-mented, and documented. A review of these standards by thereader will show that the nursing process and careful plan-ning of care can meet several standards just by writing anursing care plan.

It is not uncommon to hear, “I don’t do care plansbecause I don’t have time to do them.” It is true that there isan investment of time in completing and documentingthe nursing process, but in the long-range view, such plan-ning of care actually saves time. To illustrate, one nurse,known to the authors, works full time in nursing educa-tion but works part time at a local hospital to keep herclinical skills current. One afternoon she went to work atthe hospital, received her patient assignments and a briefreport, and then began to implement patient care. One nurs-ing order read, “Change dressing as needed.” Assessmentof the dressing showed a change was needed. In the patient’sroom were all kinds of dressings, fluids, and ointments.There were no instructions for changing the dressing on thecare plan or the patient’s chart. The nurse then requestedinformation from the patient who stated, “I don’t like to lookat it, so I don’t know.” The nurse then began to search fora staff member who had cared for this patient and couldteach her the routine for the special dressing change. After30 minutes, she finally found a nurse who had cared for thepatient. Learning the proper dressing change took only afew minutes. The nurse then went back to the care plan, andin 3 minutes recorded the way to change the dressing undernursing orders.

Comparing the time it took to locate the informationand the time it took to record the information gives a graphicexample of how time can be saved by completing and docu-menting the nursing process. Consider the time saved if thewritten nursing actions are used as an outline for charting, orthe time that could be saved in between shift reports if doc-umentation of the nursing process was complete. Lastly,consider the time that could be saved by not having to go tocourt when questions arise over reasonable prudent care.Making time to use and document the nursing processbecause we can see its value to us actually saves us time inthe long run.

SUMMARY

The nursing process provides a strong framework thatgives direction to the practice of nursing. By completingeach phase, you can reassure yourself that you are provi-ding quality, individualized care that meets local, state, and

national standards. By using the NANDA nomenclature andby providing feedback to NANDA, you can help developthis nomenclature and help ensure that nursing is recognizedfor the contributions it makes to our nation’s health.

R E F E R E N C E S

1. Ulrich, B: A matter of trust: Public continues to regard nurses highlyin honesty and ethics. Nurse Week, Dec. 17, 2001.

2. Beaumont, L: Nurses win public’s trust. USA Today, January 8, 2004www.theage.com.

3. North American Nursing Diagnosis Association International.NANDA Nursing Diagnoses: Definitions and Classification,2005–2006, NANDA International, Philadelphia, 2005.

4. McCloskey-Dochterman, J, and Bulechek, GM: Nursing InterventionsClassification. CV Mosby, St. Louis, 2004.

5. Moorhead, S, Johnson, M, and Mass, M: Nursing OutcomesClassification. CV Mosby, St. Louis, 2004.

6. Gordan, M: Nursing Diagnoses: Process and Application, ed 3.Mosby-Year Book, St. Louis, 1994.

7. Gordon, M: Manual of Nursing Diagnoses. CV Mosby, St. Louis,2002.

8. Iyer, PW, Taptich, BJ, and Bernocchi-Losey, D: Nursing Process andNursing Diagnosis, ed. 3. WB Saunders, Philadelphia, 1995.

9. Lunney, M: Critical Thinking and Nursing Diagnosis: Case Studiesand Analyses, NANDA, Philadelphia, 2001.

10. Gardner, P: Nursing Process in Action. Thomson Delmar Learning,Clifton Park, NY, 2003.

11. Doenges, ME, and Moorhouse, MF: Nurse’s Pocket Guide: NursingDiagnosis with interventions, ed 6. FA Davis, Philadelphia, 1998.

12. Alfaro, R: Applying Nursing Diagnosis and Nursing Process: A stepby step approach. Lippincott-Raven, Philadelphia, 1988.

13. American Nurses Association: Nursing’s Social Policy Statement,Washington, DC: nurse books.org, 2003.

14. American Nurses Association: Nursing: Scope and Standards ofPractice. American Nurses Association, Silver Spring, MD, 2004.

15. Texas Board of Nurse Examiners: Standards of Nursing Practice. Rule217.11.2004. Texas Administrative Code Title 22 Part 11 Chapter 217,Austin, Texas, 2004.

16. Brider, P: Who killed the nursing care plan? Am J Nurs 91:35, 1991.17. Henry, SB, Holzemer, WL, and Reilly, CA: The relationship between

type of care planning system and patient outcomes in hospitalizedAIDS patients. J Adv Nurs 19:691, 1994.

18. Webster, J: The effect of care planning on quality of patient care. ProfNurse 14(2):85, 1998.

19. JCAHO: Comprehensive Accreditation Manual for Hospitals; TheOfficial Handbook, Joint Commission Accreditation of HealthcareOrganizations, Chicago, 2005.

20. Carroll-Johnson, R: Reflections on the ninth biennial conference. NursDiag 1:50, 1991.

21. Kozier, BB, Erb, GH, and Olivieri, R: Fundamentals of Nursing,updated ed 6. Addison-Wesley Nursing, Menlo Park, CA, 2002.

22. Tartaglia, MJ: Nursing diagnosis: Keystone of your care plan. Nursing15:34, 1985.

23. Kieffer, JS: Nursing diagnosis can make a critical difference. NursingLife 4:18, 1984.

24. Bolander, VB: Sorensen and Luckmann’s Basic Nursing: APsychophysiologic Approach, ed 3. WB Saunders, Philadelphia, 1994.

25. Cox, HC: Developing Nursing Care Plan Objectives: A ProgrammedUnit of Study. Texas Tech University Health Sciences Center Schoolof Nursing, Continuing Education Program, Lubbock, TX, 1982.

26. Lampe, S: FOCUS Charting, ed 4. Creative Nursing Management,Minneapolis, MN, 1988.

27. Siegrist, L, Deltor, R, and Stocks, B: The PIE system: Planning anddocumentation of nursing care. Quality Rev Bull June, 1986

28. Burke, LJ, and Murphy, J: Charting by Exception. John Wiley &Sons, New York, 1988.

29. Schuster, P: Concept Mapping: A critical-thinking approach to careplanning, FA Davis, Philadelphia, 2002

30. Schuster, P: Concept maps in clinical settings: Improved clinical per-formance and effective patient care. Dean’s Notes 23(3):1, 2003.

31. Pehler, S, and Bodenbender, K: Concept maps as a tool for learningstandardized languages. Int J Nurs Terminol Classif 14(4):39, 2003.

Summary 23

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32. All, AC, Huycle, L, and Fisher, M: Instructional tools for nursing edu-cation: Concept maps. Nurs Educ Perspect 24(6):311, 2003.

33. Jaco, MK, Gordon, MD, and Marvin, JA: Nursing rounds link nursingdiagnoses to clinical practice. Int J Nurs Terminol Classif 14(4):53,2003.

34. Hsu, L, and Hsieh, S: Concept maps as an assessment tool in a nurs-ing course. J Prof Nurs 21(3):141, 2005.

35. Kataoka-Yahiro, M, and Saylor C: A critical thinking model for nurs-ing judgment. Nurs Educ 33(8):351,1994.

36. Yura, H, and Walsh, MB: The Nursing Process: Assessing, Planning,Implementing, Evaluating, ed 5. Appleton-Century-Crofts, EastNorwalk, CT, 1988.

37. Gordon, M: Manual of Nursing Diagnosis: 1995–1996. McGraw-Hill,New York, 1995.

38. Roy, C, Sr: Historical perspective of the theoretical framework for theclassification of nursing diagnosis. In Kim, MJ and Moritz, DA (eds):

Classification of Nursing Diagnosis: Proceedings of the Third andFourth National Conferences. McGraw-Hill, New York, 1982, p 235.

39. Roy, C, Sr: Framework for classification system development:Progress and issues. In Kim, MJ, McFarland, GK, and McLane, AM(eds): Classification of Nursing Diagnosis: Proceedings of the FifthNational Conference. McGraw-Hill, New York, 1984, p 29.

40. Kritek, PB: Report of the group who worked on taxonomies. InKim MJ, McFarland GK and McLane AM (eds): Classification ofNursing Diagnosis: Proceedings of the Fifth National Conference.McGraw-Hill, New York, 1984, p 46.

41. Newman, MA: Looking at the whole. Am J Nurs 84:1496, 1984.42. North American Nursing Diagnosis Association: Taxonomy I with

Complete Diagnoses. Author, St. Louis, 1987.43. Fitzpatrick, JJ: Taxonomy II: Definitions and development. In Carroll-

Johnson, RM (ed): Classification of Nursing Diagnosis: Proceedingsof the Ninth Conference. Lippincott, Philadelphia, 1991.

24 Introduction

••••••


2HEALTHPERCEPTION–HEALTHMANAGEMENT PATTERN1. ENERGY FIELD, DISTURBED 36

2. HEALTH MAINTENANCE, INEFFECTIVE 42

3. HEALTH-SEEKING BEHAVIORS (SPECIFY) 49

4. INFECTION, RISK FOR 54

5. INJURY, RISK FOR 59A. Suffocation, Risk forB. Poisoning, Risk forC. Trauma, Risk for

6. LATEX ALLERGY RESPONSE, RISK FOR AND ACTUAL 70

7. MANAGEMENT OF THERAPEUTIC REGIMEN, EFFECTIVE 75

8. MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL,FAMILY, COMMUNITY), INEFFECTIVE 80

9. MANAGEMENT, READINESS FOR ENHANCED THERAPEUTICREGIMEN 92

10. PERIOPERATIVE-POSITIONING INJURY, RISK FOR 96

11. PROTECTION, INEFFECTIVE 100

12. SURGICAL RECOVERY, DELAYED 107

13. SUDDEN INFANT DEATH SYNDROME, RISK FOR 111


PATTERN DESCRIPTION

A client’s perceived understanding of health and well-beingand of how health is managed is a pattern description. Itincludes the individual’s perception of health status and itsrelevance to current activities and future planning. Alsoincluded is the individual’s health risk management andgeneral health-care behavior, such as safety practices andadherence to mental and physical health promotion activi-ties, medical or nursing prescriptions, and follow-up care.1

PATTERN ASSESSMENT

1. Review the patient’s vital signs. Is the temperaturewithin normal limits?a. Yesb. No (Risk for Infection; Ineffective Protection)

2. Review the results of the complete blood cell (CBC)count. Are the cell counts within normal limits?a. Yesb. No (Risk for Infection; Ineffective Protection)

3. Review sensory status (sight, hearing, touch, smell,and taste). Is the patient’s sensory status within normallimits?a. Yesb. No (Risk for Injury)

4. Were the patient and family satisfied with the usualhealth status?a. Yesb. No (Health-Seeking Behavior; Ineffective Health

Maintenance)5. Did the patient, family, or community describe the usual

health status as good?a. Yes (Readiness for Enhanced Therapeutic Regimen

Management)b. No (Health-Seeking Behavior; Ineffective Health

Maintenance)6. Had the patient, family, or community sought any

health-care assistance in the past year?a. Yes (Health-Seeking Behavior)b. No (Ineffective Health Maintenance)

7. Did the patient or family follow the routine the (doctor,nurse, dentist, etc.) prescribed?a. Yes (Effective Management of Therapeutic Regimen;

Readiness for Enhanced Therapeutic RegimenManagement)

b. No (Noncompliance; Ineffective Management ofTherapeutic Regimen; Risk for Sudden Infant DeathSyndrome)

8. Did the patient or family have any accidents or injuriesin the past year?a. Yes (Risk for Injury)b. No

9. Is there a disruption (change in temperature, color, field,movement, or sound) of the flow of energy surroundingthe person?

a. Yes (Disturbed Energy Field)b. No

10. Was the patient, family, or community able to meettherapeutic needs of all members?a. Yes (Effective Management of Therapeutic Regimen

[Individual, Family, Community])b. No (Ineffective Management of Therapeutic

Regimen [Individual, Family, Community])11. Is the patient scheduled for surgery or has he or she

recently undergone surgery?a. Yes (Risk for Perioperative-Positioning Injury)b. No

12. Does the patient exhibit eczema?a. Yes (Latex Allergy Response)b. No

13. Does the patient have a history of multiple surgeries orlatex reactions?a. Yes (Risk for Latex Allergy Response)b. No

14. Is the patient’s surgical incision healing properly?a. Yesb. No (Delayed Surgical Recovery)

15. Does the patient express a desire to manage his/herillness?a. Yes (Readiness for Enhanced Therapeutic

Management)b. No

CONCEPTUAL INFORMATIONA person who practices health management techniques, suchas exercising regularly, paying attention to diet, and main-taining a balance of rest and activity, has an accurate view ofhis or her, or his or her family’s, personal health status.These individuals can also identify other ways to maintainhealth, and will be accurate in reporting their current healthstatus. They also readily identify alterations or changes inhealth status and take active steps to correct these changes toincrease their movement toward optimal health. In addition,they will initiate measures to prevent further alterations inhealth status. The goal of health management is to assist allpatients in achieving this level of health maintenance.

Various factors influence a person’s ability to achieveoptimal health perception (understanding) and health man-agement (control). Martha Rogers describes human beingsas energy fields.2 Disturbance in these fields can producesymptoms. A major factor affecting health is individualand/or family interaction with the environment.2 Interactionwith the environment increases the likelihood that environ-mental hazards will play a role in health managementthrough an individual’s increased exposure to problemareas. Health protection activities can reduce environmentalhazards and increase optimal health management. Examplesof such activities include individual and community effortsto reduce/eliminate air pollution, ensure a safe water supply,and manage sewage and hazardous waste disposal.

26 Health Perception–Health Management Pattern

••••••


Another major factor affecting health promotion is anintact sensory system. Sensory organs provide informationto the individual regarding the environment. An intact nerv-ous system is required because it provides for optimumfunctioning of sensory, motor, and cognitive activities. Anaccurate cognitive–perceptual pattern and self-perception/self-concept pattern are necessary to achieve the optimallevel of health perception and management. The ability tothink and understand greatly impacts basic knowledge ofhealth and illness. Likewise, the individual’s feeling of self-worth and interpretation of the meanings of health and ill-ness to the self, influences his or her health practices.Knowledge related to health promotion and disease preven-tion is essential for the individual to fully maintain healthmanagement.

Cultural, societal, and familial values and beliefsinfluence the capacity to achieve positive health perceptionand health management. Values and beliefs influence what isidentified as optimal health. Availability of appropriatehealth-care resources in a community impacts the health-care delivery system and the ability of the community tomanage a therapeutic regimen. The development of nursingdiagnoses for communities requires nurses to also developinterventions to influence health policy and to work withadvocacy groups.3

The Health Belief Model4 (Fig. 2.1) provides a frame-work in which to study actions taken by individuals to avoidillness. A basic assumption of the model is that the subjec-tive state of the individual is more important in determining

actions than the objective reality of the situation. The HealthBelief Model states that for an individual to take action toavoid a disease, she or he needs to believe the following:

1. That she or he is personally susceptible to disease.2. That the occurrence of the disease will have at least a

moderate impact on some part of her or his life.3. That taking action will be beneficial.4. That such action will not involve overcoming psycho-

logical barriers such as cost, pain, or embarrassment.

These beliefs can be described as variables that defineperceived benefits and barriers to taking actions under theheadings “perceived susceptibility” and “severity.” Becausethese variables do not account for the activation of thebehavior, the originators of the Health Belief Model haveadded another class of variable called “cues to action.” Theindividual’s level of readiness provides the energy to act,and the perception of benefits provides a preferred mannerof action that offers the path of least resistance. A cue toaction is required to set off this appropriate action. Themodel suggests that by manipulating any combination ofvariables affecting action, the inclination to seek preventivecare can be changed.

The Health Belief Model does not contain conceptsrelated to knowledge of disease as a potential factor in deter-mining an individual’s decision to engage in preventivebehavior. Several authors point out that knowledge of healthconsequences has only a limited relationship to the occur-rence of the desired health behavior.5–7 Yet, quite often,

Conceptual Information 27

••••••

Demographic variables (age, sex, race, ethnicity, and so on)Sociopsychological variables (personality, social class, peer and reference-group pressure, and so on)Structural variables (knowledge about disease, prior contact with the disease, and so on)

Cues to action: Mass media campaigns Advice from others Reminder postcard from physician or dentist Illness of family member or friend Newspaper or magazine article

Perceived threat of disease X

Modifying Factors

Perceived benefits of preventiveaction minus perceived barriersto preventive action

Likelihood of takingrecommended preventive healthaction

Likelihood of Action

Perceived susceptibility to disease XPerceived susceptibility (severity) of disease X

Individual Perception

F I G U R E 2 . 1 The Health Belief Model. (From Becker, MH, et al: Selected psychoso-cial models and corrrelates of individual health-related behaviors, Medical Care 15:27,1977 [Suppl], with permission.)


imparting knowledge about diseases to the patient, in aneffort to encourage future preventive behavior, is the mainmethod used by nurses.

The Health Belief Model is disease specific. Themodel does not adequately explain positive health actionsdesigned to maximize wellness, fulfillment, and self-actual-ization. Although the Health Belief Model is useful in pre-dicting preventive behavior, it does not fully explainbehavior motivated by health promotion.8 More research isneeded to identify the determinants of health-promotingbehavior to increase our ability to assist the patient inachieving health promotion. Preventing energy field distur-bances, for example, is an area of research appropriate tonursing practice.

The Health Belief Model provides the nurse with theconceptual notion that by considering the patient’s percep-tion of the situation, increasing the patient’s cues to action,and decreasing the patient’s barriers to action, the nurse canenhance the possibility that the patient will engage in dis-ease prevention and early detection activities.

Pender8 points out that health promotion and diseaseprevention are complementary, but very separate, concepts.Health promotion is directed toward growth and improve-ment in well-being, whereas disease prevention conceptu-ally operates to maintain the status quo.9

The Health Promotion Model as developed by Pender8

(Fig. 2.2) provides the framework for nursing research andpractice. This model emphasizes the importance of cogni-

tive–perceptual factors in behavior regulation. Cognitive–perceptual factors—for example, understanding of theimportance of health, the definition of health, perceived self-competency, and perceived control of health—are primarymotivational mechanisms for health-promoting behavior.

Healthy People 2010 (http://www.healthypeople.gov/)8 describes the national health promotion and diseaseprevention objectives. Two major goals are addressed:

1. Increase quality and years of healthy life2. Eliminate health disparities.

The document presents baseline epidemiologic dataand projected goals for health promotion, health protection,and preventive services. Special emphasis is placed on vul-nerable populations, for example, individuals who are dis-abled or elderly and those in lower socioeconomic status andcertain ethnic groups. This document is recommended as aguide for identifying factors that influence the health per-ception–health management pattern. Strategies for interven-tion and evaluation are also included.

Whether working with individuals, families, or com-munities, the nurse should plan interventions appropriate forthe learning needs of those being targeted. Mass media cam-paigns are useful when conveying general information tolarge groups of people, but one-to-one communication ismore effective for instructing individuals in their particularcircumstances. Put Prevention into Practice (http://www.ahcpr.gov/clinic/ppipix.htm)11 is a comprehensive system


••••••

Interpersonal influences: Family, peers, providers Norms, support, models

Situational influences: Options Demand characteristics Aesthetics

Perceived benefit of action

Perceived barriers to action

Perceived self-efficacy

Activity-related affect

Behavior-SpecificCognitions and Affect

Immediate competing demands(low control) and preferences(high control)

Commitmentto a

plan of action

Healthpromotingbehavior

Participation inBehavioral Outcomes

Personal factors: Biologic Psychological Sociocultural

Prior related behavior

Individual Characteristicand Experiences

F I G U R E 2 . 2 Health Promotion Model. (From Pender, NJ: Health Promotionin Nursing Practice, ed 3. Appleton-Century-Crofts, Stamford, CT, 1996, p 58,with permission.)


that was developed to assist the clinician, and the patient andhis or her family, to establish a routine of preventive behav-iors and services. The kit includes a clinician’s handbook,preventive care timelines, office reminders, and patient-oriented materials to promote preventive behaviors.

The concepts of primary, secondary, and tertiary pre-vention11 are also useful to the nurse when using the healthmanagement pattern. It is important for the nurse to recog-nize that a focus on the patient’s strengths, not just his or herproblems, is an integral part of health promotion.12,13

Primary prevention consists of activities that prevent adisease from occurring. A patient engaged in primary pre-vention activities would:

1. Maintain up-to-date immunizations.2. Have adequate water supply and sanitation facilities.3. Use seat belts and infant car seats, and properly store

household poisons to minimize accident fatalities.4. Eliminate tobacco products.5. Maintain adequate nutrition, elimination, exercise,

social, and personal relationships, etc.6. Practice good oral hygiene and receive dental examina-

tions on a regular basis.7. Avoid excessive sun exposure and use sunscreens and

protective clothing.8. Maintain weight within normal range for age, sex, and

height.9. Maintain an environment free of chemical, biologic,

and physical hazards.10. Maintain regular sleep and rest patterns.11. Practice healthy nutritional intake (i.e., low amounts of

salt, sugar, and fat; follow food pyramid recommenda-tions for daily servings per food group and total calo-ries as appropriate for age, sex, and condition).

12. Maintain regular relaxation, recreation, and exerciseactivities.

Secondary prevention indicates activities designed todetect disease before symptoms are recognized. Screeningactivities are the most common type of secondary preven-tion activities and include:

1. Diabetes screening2. Glaucoma screening3. Hypertension screening4. Hearing and vision testing5. Pap smears6. Breast examinations7. Prostate and testicle examinations8. Well-baby examinations9. Colon and rectal examinations

Tertiary prevention refers to the treatment, care, andrehabilitation of current illness. This area indicates thepatient needs to:

1. Adhere to medical and nursing treatments.2. Make lifestyle changes necessitated by condition.

3. Seek consultation from experts in area requiring inter-vention, for example, individual practitioners and sup-port groups.

DEVELOPMENTAL CONSIDERATIONS

Health-care providers can encourage the acceptance ofresponsibility for health-promoting activities and adherenceto agreed-upon treatment plans by giving appropriate atten-tion to the impact developmental levels have on the individ-ual or the primary caregiver. Publications such as PutPrevention into Practice11,15 can assist the nurse, patient,family, and community in establishing a routine of health-promoting behaviors and practices. The US Administrationon Aging (AoA) offers many publications and programs tosupport the healthy aging of older Americans (http://www.aoa.gov/). One of the programs of the AoA, You Can!Steps to Healthier Aging, provides specific suggestions andactivities for older adults to stay active and healthy (http://www.aoa.gov/youcan/youcan.asp).

INFANT AND TODDLER

Because the neonate is totally dependent on others for care,it is the primary caregiver who is entrusted with carrying outthe therapeutic interventions. As the infant grows and devel-ops, self-care abilities increase. The following informationoutlines developmental milestones from birth to approxi-mately 24 months, as described by Piaget’s sensorimotorstage of cognitive development.14 During this period ofdevelopment, the individual must be protected from hazardsin the environment, and the primary caregiver must assumethe major share of responsibility for compliance with thetreatment program.

Providing a safe environment includes the followingaccident prevention strategies:

1. Placing infants to sleep on their back (“back to sleep”)2. Minimizing prenatal and postnatal infant smoke

exposure3. Avoiding overwrapping or overheating of infants4. Early and regular prenatal care for expectant mothers5. Turning pot handles away from edge of stove6. Storing medicines, matches, alcohol, plastic bags, and

house and garden chemicals in child-proofed areas7. Using a cold-water, not a hot-water, humidifier8. Avoiding heating formula in microwave9. Using protection screens on heaters, fireplaces, and

electrical outlets10. Using nonflammable clothing11. Gating stairways and windows12. Supervising children at play, while bathing, in car, or in

shopping cart13. Controlling pets or stray animals14. Avoiding items hung around neck15. Providing a smoke-free environment

Developmental Considerations 29

••••••


16. Avoiding small objects that can be inserted in mouthor nose

17. Avoiding pillows and plastic in crib18. Removing poisonous plants from house and garden19. Removing lead-based paint from the home

Children should be screened at birth for congenitalanomalies, phenylketonuria (PKU), thyroid function, cysticfibrosis, vision impairment, and hearing deficiency. A new-born assessment should be performed, and anticipatoryguidance should be provided for patients regarding growthand development, safety, health promotion, and disease pre-vention.

Well-baby examinations and developmental assess-ments are recommended at 2, 4, 6, 15, and 18 months.11,16–18

Height and weight should be recorded on growth charts, andhemoglobin and hematocrit should be checked at least onceduring infancy. Parent counseling includes discussion ofnutrition with attention paid to iron-rich foods; safety andaccident prevention; oral, perineal and perirectal hygiene;sensory stimulation of the infant; baby-bottle tooth decay;and the effects of passive smoking. Immunizations are givenduring the well-baby checks according to the followingschedule19,20:

1. Hepatitis B-1 at birth to 2 months2. Hepatitis B-2 at 1 to 4 months3. DTaP (diphtheria and tetanus toxoids and acellular

pertussis) or DTP (diphtheria, tetanus toxoids, and per-tussis), HiB (Haemophilus influenzae type B), pneumo-coccal conjugate (PCV), and polio at 2 and 4 months

4. DTaP, CPV, and HiB at 6 months5. Hepatitis B-3 and polio at 6 to 18 months6. HiB at 12 to 15 months20–23

7. MMR (measles, mumps, and rubella), varicella, PCV,and tuberculin test at 12 to 18 months

8. DTaP or DTP at 15 to 18 months9. PCV at 2 to 5 years

10. DTaP or DTP, polio, and MMR at 4 to 6 years11. Hepatitis B, Td (tetanus and diphtheria toxoid), MMR,

and varicella at 11 to 12 years23

For children who have not been immunized during thefirst year of life, you will need to consult the latest estab-lished standards for appropriate timetables.19,24 Hepatitis Bvaccine (HBv) should be given at birth, 2 to 4 months, and6 to 18 months.19,24 HBv can be administered at the sametime as DTP and/or Haemophilus influenzae type B con-jugate vaccine (HibCV).24 The Centers for Disease Controland Prevention recommends yearly administration ofinfluenza vaccine beginning at age 6 months (2005).25–27

Host factors such as age and behavior affect the sus-ceptibility to infectious disease. In general, most infectiousdiseases produce the greatest morbidity and mortality inthe very old and the very young (http://www.cdc.gov/nip/vaccine/tdap/tdap_adult_recs.pdf).26,28 It is also important tonote that the normal newborn has a white blood cell count

that is higher than that of the normal adult. The normalwhite blood cell count decreases gradually throughout child-hood until reaching the adult norms.27,28 It is essential thatthe nurse be very familiar with the blood cell count normsfor this age group.

During fetal life, maternal antibodies (assuming themother has developed them) protect the fetus from diseasessuch as diphtheria, tetanus, measles, and polio. This tempo-rary immunity lasts 3 to 6 months. Colostrum contains anti-bodies that provide protection against enteric pathogens.Some infections can cross the placental barrier, leading tothe development of congenital (present at birth) infections.Syphilis, human immunodeficiency virus (HIV), and rubellaare examples of such infections. Pathogenic organisms suchas herpes simplex may be acquired during passage throughthe birth canal. Because infants do not begin to produceimmunoglobulins until 2 to 3 months after birth, they aresusceptible to infections for which they have not gained pas-sive immunity.

Infections can be of serious concern during the peri-natal period, especially TORCH infections (Toxoplasmosis,Hepatitis B, Rubella, Cytomegalovirus, Herpes). Otherinfections such as Chlamydia, group B Streptococcus,syphilis, HIV, and acquired immunodeficiency syndrome(AIDS) are also of great concern as all of these infectionshave consequences for not only the pregnancy, but also thenewborn.29 When caring for a pregnant woman or a new-born, it is important to teach techniques to prevent acquisi-tion and transmission of these disorders and to recognizeearly signs and symptoms so that early interventions can beinstituted. For newborns, the HBv series should be initiatedat birth before discharge from the hospital.20–24,26

Child-care practices must include hygienic disposal ofsoiled diapers and cleaning of the perineum. Proper hand-washing techniques are required of the care provider. Properformula preparation and storage are also critical if the new-born is to be bottle-fed. Anatomically, the eustachian tube ofthe newborn and infant facilitates the passage of infection-causing organisms into the middle ear. It is important forcare providers not to prop bottles, but rather to hold the new-born or infant while feeding. Passive exposure to tobaccosmoke irritates the bronchial tree and increases the possibil-ity of respiratory infection.

The infant may respond to an infection with a veryhigh fever. Care providers should be taught how to do thefollowing: take axillary or tympanic temperatures, providehydration to an ill infant, give tepid baths when fever is ele-vated, and seek professional evaluation when an infant has afebrile illness.

TODDLER AND PRESCHOOLER

During the preoperational period, children learn how toteach themselves through trial and error, exploration, andrepetition. From age 2 to 4 years, the child is egocentric,using him- or herself as a standard for others; he or she can


••••••


categorize on the basis of a single characteristic. Because ofthe child’s curiosity and exploration of the environment, it isimportant for the care provider to provide a safe environ-ment. During this period the words “no,” “hot,” “sharp,” and“hurt” should be introduced and repeatedly reinforced bythe care provider. Safety rules should also be taught andreinforced repeatedly.

From ages 4 to 7 years, the child can begin to see sim-ple relationships and is developing the ability to think in log-ical classes. The child can learn his or her own address andcan follow directions of three steps. Rules need to be rein-forced. The child can be responsible for personal hygienewith instruction and coaching.

Strategies used to provide a safe environment for theinfant should also be used during childhood. Discipline, acci-dent prevention, and the development of self-care proficiencyrelated to eating, dressing, bathing, and dental hygiene areimportant areas of concern. Developmental assessments withemphasis on hearing, vision, and speech are recommended.DPT or DTaP, and OPV (oral polio vaccine) or IPV (inacti-vated polio vaccine) are given once between 4 and 6 years ofage, at or before school entry. Consult guidelines if the childhas not been immunized during the first year of life.19–24 TheImmunizations Practices Advisory Committee (ACIP) of theU.S. Public Health Service30 recommends that a second doseof MMR be given at 4 to 5 years of age, when the child enterskindergarten.

Anticipatory guidance should be given to parents onthe development of initiative and guilt, nutrition and exer-cise, safety and accident prevention, toothbrushing and den-tal care, effects of passive smoking, and skin protectionfrom ultraviolet light.17 In addition, the parents should betaught that, as the child begins to explore the environmentand put objects and foods into his or her mouth, it will beimportant to ensure that contact with infectious pathogens orforeign bodies is controlled. Foreign-object-induced infec-tion should be considered in childhood infections of theexternal ear, nose, and vagina.

If the preschooler has been exposed to other children,he or she most likely will have experienced several middleear, gastrointestinal, and upper respiratory tract infections. Ifthe child has not been around other children, he or she willlikely experience such infections when entering preschoolor kindergarten. Preventing injury will also assist in the pre-vention of infection. The adenoidal and tonsillar lymphoidtissue may normally enlarge during the early school years,partly in response to the exposure to pathogens in school.

The child will require assistance with toiletinghygiene until 4 to 5 years of age. Handwashing techniquescan be introduced along with toilet training and followedwith consistent role modeling by the adults and older chil-dren who provide assistance to the child. Bubble baths andother scented soaps and toilet tissue may irritate the urethrain the female child and lead to urinary tract or vaginal infec-tions. Parents, grandparents, other caregivers, and the childshould be taught to avoid such items. In addition, proper

dental hygiene can be taught to the child to help preventtooth and gum infections.

SCHOOL-AGE CHILD

This period is characterized by developing logicalapproaches to concrete problems. The concepts of reversibil-ity and conservation are developed, and the child can organ-ize objects and events into classes and arrange them in orderof increasing values. The child can be responsible for per-sonal hygiene and simple household tasks. The child willneed assistance when ill, but he or she can be taught self-careactivities as required, such as insulin injections or takingmedications on a regular basis. The child can distinguish anddescribe physical symptoms and report them to the appro-priate caregiver, and he or she can follow instructions.

Strategies used by care providers to establish a safeenvironment, prevent disease, and promote health can betaught to the child. The child can perform many of thesefunctions with supervision. Emphasis is placed on healtheducation of the child in safety and accident prevention,nutrition, substance abuse, and anticipated changes withpuberty. Anticipatory guidance for both the parents and thechild should include the development of industry and avoid-ance of inferiority. A preadolescent immunization statuscheck is recommended at 11 to 12 years of age.20,21 HepatitisB vaccine is recommended for those who did not receive thevaccine as a child. Screening of high-risk groups for tuber-culosis is recommended.11

ADOLESCENT

True logical thought is developed and abstract concepts canbe manipulated by individuals at this developmental level. Ascientific approach to problem solving can be planned andimplemented. The adolescent can develop, with guidance,responsibility for total self-care. With experience, the ado-lescent requires less guidance and can assume full decision-making responsibility and total responsibility for self-care.

Emphasis should be placed on health education of theadolescent in healthy living habits, safe driving, sex educa-tion, skin care, substance abuse, career choices, relation-ships, dating and marriage, breast self-examination forfemale adolescents, and testicular self-examination for maleadolescents. Screening for pregnancy, sexually transmitteddiseases, depression, high blood pressure, and substanceabuse can be done. Anticipatory guidance should be given toparents and adolescents about the development of identity,role confusion, and formal operational thought.17

The hormonal changes of puberty may lead to acnevulgaris. If severe, proper hygiene and dermatologic evalua-tion will prevent serious complications. The changes in thevaginal tissue secondary to hormonal changes provide anenvironment conducive to yeast infections. If the adoles-cent is engaging in sexual activity, he or she is at risk forexposure to sexually transmitted diseases. Irritants such assoap and bubble bath may increase the possibility of urinary


••••••


tract infection in female adolescents. Improper genitalhygiene also predisposes the female adolescent to urinarytract infections.

Persons born after 1956 who lack evidence of immu-nity to measles should receive the MMR vaccine.20,30 TheMMR vaccine should not be given during pregnancy.Individuals susceptible to mumps should be vaccinated aswell.25,31 A diphtheria and tetanus vaccination (Td) should begiven at 14 to 16 years of age. Hepatitis B vaccines shouldbe given to anyone who did not receive immunizations as achild.21 Screening of high-risk groups for tuberculosis is rec-ommended.11 Adolescents living in a group setting, such as adormitory, have an increased risk of contracting a communi-cable disease. Good personal hygiene is important todecrease this risk.

Meningococcal vaccine is recommended for all chil-dren at their routine preadolescent visit (11 to 12 years ofage). For those who have not previously received the menin-gitis vaccine, a dose is recommended on entry to highschool. Other adolescents who want to decrease their risk ofmeningococcal disease can also get the vaccine. Other peo-ple at increased risk, for whom routine vaccination is rec-ommended, are college freshmen living in dormitories.32

Risk-taking behavior of adolescents32 may increase therisk of infection and accidents. Examples of these risk-takingbehaviors include sexual intercourse; IV drug use; use ofalcohol and tobacco; traumatic injury, tattooing or bodypiercing, that breaks the skin, allowing a portal of entry forpathogenic organisms; fad diets or other activities thatdecrease the overall health status; improper technique orequipment in water sports; motor vehicle accidents; runninga vehicle or other combustion engines when not properlyventilated; substance abuse; choking on food; smoke inhala-tion; improper storage and handling of guns, ammunition,and knives; smoking in bed; improper use or storage of flam-mable items, hazardous tools, and equipment; drug inges-tion; playing or working around toxic vegetation; improperpreparation and storage of food; and improper precautionsand use of insecticides, fertilizers, cleaning products, med-ications, alcohol, and other toxic substances.

ADULT

Adult thought is more refined than adolescent thoughtbecause experience and education allow the adult to differ-entiate among many points of view and potential outcomesin an objective and realistic manner. The adult can considermore options and can apply inductive, as well as deductive,approaches to problem solving. The adult assumes totalresponsibility for the care of a child. In middle adult years,the adult may also care for an elderly parent.

The adult is concerned about many of the same healthpromotion and disease prevention issues the adolescent wor-ries about. Emphasis should be placed on lifestyle counsel-ing related to family planning, parenting, stress management,career advancement, relationship enhancement, hazards atwork, and development of intimacy and generativity.

Regular breast self-examination (women) and testicu-lar self-examination (men) should be taught and encour-aged. Women should have a baseline mammogram at age 35and all women 40 and above should have a clinical breastexam and mammogram annually. Women should be advisedto have Pap smears every 1 to 2 years, or more often as rec-ommended by their primary care provider. Screening forglaucoma; high blood pressure; high blood cholesterol level;rubella antibodies; sexually transmitted diseases; and colon,endometrial, oral, or breast cancer should be done if thepatient is in a risk category.

As the body develops more antibodies to pathogens,adults may find that they do not have as many colds as theyused to. Some viral infections (e.g., mumps) may presentserious consequences to adults (particularly men in the caseof mumps). The adult female is as susceptible to genitouri-nary infections as the adolescent. Sexually active adults areat risk for sexually transmitted diseases.

Tetanus-diphtheria (Td) boosters should be givenevery 10 years. Hepatitis B vaccine should be given to peo-ple at risk for exposure. Remember, persons born after 1956who lack evidence of immunity to measles should receivethe MMR vaccine, but the MMR vaccine should not begiven during pregnancy. Individuals susceptible to mumpsshould be vaccinated. Pneumococcal and influenza vaccinesare recommended annually, especially for persons at risk foracquiring the flu, and for persons at risk for complicationsfrom infection.25 Advanced age; conditions associated withdecline in antibody levels; Native American ethnicity; andinstitutional settings such as military training camps, cor-rectional facilities, and boardinghouses all are identified asrisk factors33–35 for the development of pneumonia andinfluenza. Tuberculosis screening of high-risk populations isrecommended.11

OLDER ADULT

In the absence of illness affecting cognitive functioning, theolder adult maintains formal operational abilities. The olderadult can assume total responsibility for decision makingand self-care. The older adult also often assumes responsi-bility for the care of others, such as a spouse, child, orgrandchild. As with other developmental levels, illness orphysical disability can alter the cognitive functioning andlead to self-care deficits.

Emphasis is on health education related to retirement,safety in the home, medication use, living with chronic ill-ness, and grandparenting.36 Anticipatory guidance is relatedto the development of ego integrity. The importance of reg-ularly scheduled breast self-examinations, Pap smears,mammography (women), and testicular self-examination(men) should be taught and the practices encouraged.Glaucoma, blood pressure, cholesterol, and colon cancerscreenings should also be done.37 Podiatry care should begiven as needed. Tetanus-diphtheria (Td) boosters; hepatitisB and A vaccines; and pneumonia, and varicella immuniza-tions are given according to the same conditions discussed


••••••


in the adult health section.38,39 Older adults, who are often atrisk for serious complications resulting from influenzainfection, should have an annual influenza immunization.25

The influenza vaccine should be given annually bothto people 65 and older and to younger people in high-riskgroups. The pneumococcal vaccine should be given onetime to people 65 years of age or older and to younger peo-ple in high-risk groups. If the older adult is at very high riskfor pneumococcal infection, the vaccine may be given again6 years after the initial immunization.38,39 Although theworldwide incidence of tetanus is decreasing, older adultsremain more susceptible to the disease. Tuberculosis casesin the United States remain disproportionately distributed inthe older population and in people with acquired immunitydiseases.40

The inability to achieve adult immunization recom-mendations is a serious problem in the United States. It isestimated that only 58 percent of adults age 65 and olderreceive the influenza vaccine, and only 35 percent receivethe pneumococcal vaccine.10 This number is markedlydecreased for older Hispanic and African American adults.10

To improve vaccination coverage of older adults, theNational Guidelines Clearinghouse guidelines (http://www.guideline.gov) recommends interventions to enhance accessto vaccination services, provider or system based interven-tions, and interventions in increase client demand for vacci-nation services. Interventions to enhance access tovaccination services for older adults include expandedaccess to vaccinations in health-care settings and reducingthe client’s out-of-pocket costs for vaccinations. Provider orsystem based interventions include provision of standingorders for clients when indicated, provider reminder sys-tems, and provider assessment and feedback. Interventions

to increase client demand for vaccination services includeclient reminder systems and client education.

Older adults may have a decreased ability to removethemselves from hazardous situations as a result of changesin mobility. Olfactory alterations may lead to an inability tosmell smoke or gas fumes.40 The risk for injury and increasesin self-care deficits may result from sensory, motor, or per-ceptual difficulties.

Age-related changes in the immune system can lead toincreased severity and number of infections in the olderadult.38–40 Physical aging changes in the skin, respiratory,gastrointestinal tract, and genitourinary system can lead toincreases in infection. Skin breakdown due to epidermalthinning and decreased skin elasticity, less effective cough-ing, diminished gag reflex, decreased gastrointestinal motil-ity, and urinary stasis can be problematic for the older adultwith a less efficient immune system. Changes in the numberand maturity of T-lymphocyte cells lead to decreased abilityof the body to destroy infectious organisms. B-lymphocytecells, producing immunoglobulins, are less efficient in thepresence of fewer and weaker T cells.38,41

Older adults with chronic illnesses who are hospi-talized or who are in a nursing home are at increased riskfor infection. When assessing older adults for infection, itis important for the nurse to realize that the signs of infec-tion can be altered with aging. With the aging-relatedchanges of the immune system, and problems with temper-ature regulation, it is not unusual for seriously ill olderadults to be afebrile while suffering from an infection.Atypical symptoms leading the nurse to suspect infection inthe older adult include mental status changes, anorexia,functional decline, fatigue, falls, and new or worsened uri-nary incontinence.40–43


••••••

T A B L E 2 . 1 NNN Taxonomy Linkages

GORDON’S FUNCTIONAL NANDA NURSING NIC PRIORITY HEALTH PATTERN DIAGNOSIS INTERVENTIONS NOC EVALUATIONS

Health Perception/HealthManagement Pattern

Energy Field Disturbed

Health Maintenance,Ineffective

Therapeutic Touch

Health SystemGuidance

Support SystemEnhancement

Personal Health StatusPersonal Well-BeingSpiritual HealthHealth Belief: Perceived

ResourcesHealth-Promoting BehaviorHealth-Seeking BehaviorKnowledge: Health Behavior;

Health Promotion; HealthResources; Treatment Regime

Participation in Health-CareDecisions

Personal Health StatusRisk DetectionSelf-Care StatusStudent Health Status




••••••

T A B L E 2 . 1 NNN Taxonomy Linkages (continued from page 33)


Health-SeekingBehaviors (specify)

Infection, Risk for

Injury, Risk for

Health EducationSelf-Modification

Assistance

Immunization/VaccinationManagement

Infection ControlInfection Protection

Electronic Fetal Monitoring:Intrapartum

Fall PreventionLabor InductionLatex PrecautionsMalignant Hyperthermia

Precautions

Adherence BehaviorHealth BeliefsHealth OrientationHealth-Promoting BehaviorHealth-Seeking BehaviorKnowledge: Health PromotionKnowledge: Health ResourcesPersonal Well-BeingAspiration PreventionCommunity Risk Control:

Communicable DiseaseHealth BeliefsHemodialysis AccessImmobility Consequences:

PhysiologicalImmune StatusImmunization BehaviorInfection SeverityInfection Severity: NewbornKnowledge: Infection Control;

Treatment Procedure(s)Nutritional StatusRisk ControlRisk Control: Sexually

Transmitted Diseases (STD)Risk DetectionSelf-Care; HygieneTissue Integrity: Skin and

Mucous MembranesTreatment Behavior: Illness or

InjuryWound Healing: Primary

IntentionWound Healing: Secondary

IntentionAbuse ProtectionAllergic Response: SystemicAspiration PreventionBalanceBlood Glucose LevelBlood Loss SeverityCoordinated MovementFall Prevention BehaviorFalls OccurrenceKnowledge: Body Mechanics;

Child Safety; Fall Prevention;Personal Safety

Maternal Status: PostpartumParenting: Infant/Toddler,

Early/Middle ChildhoodPhysical Safety;Psychosocial Safety

Personal Safety Behavior



••••••



Latex Allergy Response

Therapeutic RegimenManagement, Effective

Therapeutic RegimenManagement,Ineffective

Therapeutic RegimenManagement,Readiness forEnhanced

Perioperative Positioning,Injury, Risk for

Allergy ManagementLatex Precautions

Anticipatory GuidanceHealth System Guidance

Behavior ModificationSelf-Modification

Assistance

* still in development

Positioning:Intraoperative

Skin Surveillance

Physical Injury SeverityRisk ControlRisk Control: Hearing or Visual

ImpairmentRisk DetectionSafe Home EnvironmentSeizure ControlSelf-Care StatusAllergic Response: LocalizedImmune Hypersensitivity ResponseTissue Integrity: Skin and Mucous

MembranesAdherence BehaviorCompliance BehaviorFamily Participation in Professional

CareKnowledge: Treatment RegimeParticipation in Health-Care

DecisionsRisk ControlSymptom ControlTreatment Behavior: Illness or InjuryCompliance BehaviorKnowledge: Diet; Treatment

RegimenParticipation in Health Care

DecisionsSymptom ControlTreatment Behavior: Illness or InjuryAdherence BehaviorCompliance BehaviorFamily Participation in Professional

CareKnowledge: Treatment RegimenParticipation in Health-Care

DecisionsRisk ControlSymptom ControlTreatment Behavior: Illness or InjuryAllergic Response: SystemicAspiration PreventionBlood CoagulationBlood Loss SeverityCirculation StatusCognitionCognitive OrientationFluid Overload SeverityImmune StatusMedication ResponseNeurologic Status: Spinal Sensory/

Motor FunctionRespiratory Status: Gas Exchange;

VentilationRisk ControlRisk DetectionThermoregulation



••••••

T A B L E 2 . 1 NNN Taxonomy Linkages (continued from page 35)


*Linkages to these concepts are not present in current NANDA, NIC, and/or NOC literature.

Protection, Ineffective

Sudden Infant DeathSyndrome, Risk for

Surgical Recovery,Delayed

Electronic Fetal Monitoring:Intrapartum

Environmental Management:Violence Prevention

Infection ControlInfection ProtectionPost-Anesthesia CareSurgical PrecautionsSurveillance: Safety*still in development

Incision Site CareNutrition ManagementPain ManagementSelf-Care Assistance

Tissue Integrity: Skin and MucousMembranes

Tissue Perfusion: PeripheralAbuse ProtectionCommunity Violence LevelHealth Beliefs: Perceived Ability to

PerformHealth-Promoting BehaviorImmune StatusImmunization BehaviorKnowledge: Personal SafetyPersonal AutonomyKnowledge: Infant Care; ParentingParenting: Infant/Toddler Physical

SafetyParenting PerformancePrenatal Health BehaviorPreterm Infant OrganizationRisk ControlRisk Control: Tobacco UseRisk DetectionThermoregulation: NewbornAmbulationBlood Loss SeverityEnduranceFluid Overload SeverityHydrationImmobility Consequences:

PhysiologicalInfection SeverityNausea and Vomiting SeverityPain LevelPost Procedure Recovery StatusSelf-Care: ADLWound Healing: Primary Intention

APPLICABLE NURSING DIAGNOSES

ENERGY FIELD, DISTURBED

DEFINITION44

A disruption of the flow of energy surrounding a person’sbeing that results in disharmony of the body, mind, and/orspirit.

DEFINING CHARACTERISTICS44

Perceptions of changes in patterns of energy flow such as:

1. Movement (wave, spike, tingling, dense, flowing)2. Sounds (tone, words)

3. Temperature change (warmth, coolness)4. Visual changes (image, color)5. Disruption of the field (deficit, hole, spike, bulge,

obstruction, congestion, diminished flow in energyfield)

RELATED FACTORS44

Slowing or blocking of energy flows secondary to:

1. Pathophysiologic factors (illness, pregnancy, injury)2. Situational factors: personal or environmental (pain,

fear, anxiety, grieving)3. Treatment related factors (immobility, labor and deliv-

ery, perioperative experience, chemotherapy)


Energy Field, Disturbed 37

••••••

NURSING ACTIONS/INTERVENTIONS WITH RATIONALES

Adult Health

A C T I O N S / I N T E R V E N T I O N S R AT I O N A L E S

Establish trusting relationship with the patient.Allow the patient to talk about condition.Assess energy field.

Center self:• Imagine self as open system with energy flow content

in, through, and out of the system.• Consciously quiet your mind; put aside or detach from

inward and outward distractions.• Focus full attention and intention on helping patient.

Assess for heat or tingling over specific body areas:• Glide hands, palm down, and slowly move over body,

head to toe, 2 to 4 inches above body.Be sensitive to any images that come to mind: words,

symbols, pictures, colors, sound, mood, emotion, etc.46

Attempt to get a sense of the dynamics of the energyfield. Synthesize assessment data into an understand-able format.

Promotes accurate assessment.Promotes nurse–patient relationship.Alterations, variations, and/or asymmetry in the energy

field are detected through assessment.45

Promotes accurate assessment.

There may be a loss of energy, disruption or blockage inthe flow of energy, or an accumulation of energy in apart of the body.47

4. Maturational factors (age related developmental difficul-ties or crisis—specify)

RELATED CLINICAL CONCERNS

1. Chronic or catastrophic illness2. Trauma3. Autoimmune deficiency syndrome4. Insomnia5. Chronic fatigue syndrome6. Cancer or chemotherapy7. Recent surgery8. Sensory or perceptual disorders9. Pain

10. Birthing process (labor and delivery)

✔Have You Selected the Correct Diagnosis?

FatigueFor this diagnosis, the client will report exhaustionand lack of energy. Assessment will document anoverall reduction of energy, not a disruption ofenergy.

Activity IntoleranceThe client will relate, via interview, specific activitiesthat cannot be accomplished. Specific physical find-ings, such as abnormal pulse and respiration rates,will be present during activity.

Ineffective ThermoregulationThis diagnosis relates to temperature fluctuationsonly. Energy field disruption demonstrates other defin-ing characteristics in addition to temperature change.

Disturbed Sleep PatternA problem in the sleep–rest pattern could result inalterations in the energy field. Interviewing the personregarding sleep habits will assist in clarifying whetherthe primary diagnosis is Disturbed Sleep Pattern orDisturbed Energy Field.

Disturbed Sensory PerceptionDetermining the person’s orientation to time andplace; his or her ability to discern objects in the envi-ronment via vision, touch, sound, or smell; and his orher problem-solving abilities will assist in distinguish-ing Disturbed Energy Field from Disturbed SensoryPerception.

PainObserving for signs and symptoms of pain (facialmask, guarding behavior, moaning, or crying) willdistinguish Pain from Disturbed Energy Field.

EXPECTED OUTCOME

Assessment will demonstrate a consistent energy field by[date].

Client verbalizes an improvement in their sense ofwell-being by [date].

(care plan continued on page 38)



••••••

Child Health


Monitor for reciprocity of maternal–infant dyad.

Identify developmentally appropriate parameters to deter-mine the most conducive and therapeutic method formonitoring the child’s energy field.47,48

Monitor energy field with a focus on maintaining self-comforting activities for the child. May begin with softmusic and/or soothing voice.47,48

Begin with gentle but firm pressure of hands on oneanother.

Assess energy field from head to toe. Focus on determin-ing sites where differences are present. Refer to AdultHealth-Care Plan for additional details.

Attempt to redirect areas of lesser flow or greater flowwithin an overall free-flowing energy field, allowing 1/2to 1 inches between nurse’s hands and the child.

Provides assessment for causative factors and the mutual-ity or responsiveness between infant and caregiver.

*Consider potential effects of medications as antiseizuremeds.

Disturbed energy fields may be related to numerous otheraltered patterns due to the infant or child’s basic cop-ing repertoire, especially altered thermoregulation–altered neurologic status. Approaching the infant orchild according to cues for behavior potential yieldsgreater likelihood of stress reduction.

Will enhance assessment of energy field.

Warms hands.

Routine assessment.

Restores balance. The infant or child has a small energyfield.

NURSING ACTIONS/INTERVENTIONS WITH RATIONALES (continued from page 37)

Adult Health


Redirect areas of accumulated energy, reestablish theenergy flow, and direct energy to depleted areas.Repattern or rebalance patient’s energy field.

Do therapeutic touch for no longer than 10 minutes.

Assess the patient’s subjective reaction to therapeutictouch. Patient should feel more relaxed, less anxious,and less pain (if there were complaints of pain prior totherapeutic touch).

Teach the patient relaxation exercises using some of thesame techniques as therapeutic touch:

• Assist the patient to center self.• Teach the patient to imagine a peaceful place. Help the

patient to visualize place through all the senses and toallow the energy of the imagined place to bring about astate of calmness.

• Teach the patient to scan his or her body to self-assessareas of body or muscle tension.

• Assist the patient to consciously relax that tense area ofthe body.

• Practice relaxation at least 10 to 20 minutes a day.

Energy transfer or transformation can occur withoutdirect physical contact between two systems.45 Handsare focal points for the direction and modulation ofenergy.45

Could disrupt the energy field of the therapist.

Nurse acts as a conduit through which the environmentalor universal energy passes to the patient.45,46

Relaxation requires the patient to stop trying and to stepoutside of self and adopt a nontrying attitude. Thisallows the person to release and use the inherentenergy of self.46

Rebalances energy flow through the body.46



••••••

Women’s HealthSame as Adult Health except for the following:


Instruct in use of therapeutic touch, relaxation, imageryand visualization, paced breathing, music, acupressure,and hypnosis as a means of coping with labor pain.53

Instruct women in the use of NAC for relaxation and self-care during times of illness and stress throughout theirlife span. Some of these therapies include such practicesas acupressure and acupuncture, artistic expression,biofeedback, deep breathing, healing touch hypnosis,imagery, music, prayer, relaxation, therapeutic touchand other practices which support women’s psychoso-cial and spiritual components, as well as their physicaldomain.58–60

Provides a natural source of dealing with the discomfortof labor.53–60 Allows the woman and her newborn toexperience a drug-free labor and delivery.

NAC (Natural, alternative, complementary health-carepractices) have a limited research base at the presenttime; but women throughout the ages have used thesetechniques to become tuned into the energy surround-ing a person’s being and the harmony of body, mindand spirit. “Women have always been healers. Culturalmyths from around the world describe a time whenonly women knew the secrets of life and death, andtherefore they alone could practice the magical art ofhealing.”60

Mental Health


Explain intervention to the client in terms that facilitatereality orientation and do not exacerbate thought disor-ders.

• Use examples that elicit the client’s past experienceswith personal energy fields that do not reinforce delu-sional beliefs (e.g., EEG and EKG measure electricalenergy that flows from the body; walking across thefloor and then touching something releases the buildupof energy that can be seen or felt as a mild shock).Rubbing a balloon over the hair and watching it standup when the balloon is moved away is another example.

Prevents reinforcement of delusional system and facili-tates the development of a trusting relationship.61


Monitor the client’s responses to therapeutic touch. Focuson identifying stimulus response.

Teach the client (or family, depending on client’s age) tonote physical and mental cues that alter energy field,especially stressors.49,50

Offer age-appropriate relaxation techniques (e.g., imagi-nary floating like a feather to suggest lightness for aschool-ager vs. gentle rocking to rhythmic music for aninfant).51,52

Be mindful of contributing factors of self. Offer ways toassist the caregiver in learning techniques for mainte-nance of energy field balance.

As appropriate, assist family to develop ways to reducesensitivity to external triggering cues.

Permits evaluation of success of therapy.

Promotes early intervention.

Pays attention to developmental level.

Provides long-term assistance.

Provides long-term balance.




••••••


Mental Health


• Instruct the client that these techniques facilitate his orher own healing potential and are used in conjunctionwith other treatments.

Discuss with the client his or her perceptions or concernsabout their alterations.

Discuss with the client interventions that can assist withenergy balance. In consultation with the client selectone of the following methods for altering energy fieldsbased on the assessment:

• Therapeutic touch• Foot or hand reflexology• Visual imagery• Visualization with relaxation techniques• Acupressure• Transcutaneous electrical nerve stimulation (TENS)• Biofeedback

Note referral information here with date and time ofappointment with practitioner.

If the nurse is prepared to implement the intervention,prepare the client and environment for the applicationof the intervention:

• Provide private, quiet environment.• Teach the client about the intervention.• Obtain the client’s permission to utilize the

intervention.• Provide appropriate music that increases the client’s

feelings of comfort.• Provide essential oils or other scents that enhance the

client’s sense of well-being.

Focus own attention on the intent of the interaction.

Inform the client that he or she should tell the practitionerif there are any differences in the way he or she feelsduring the application of the technique. This couldinclude feelings of relaxation, warmth, or change inbreathing patterns.

Assist the client into a comfort position that will facilitatetreatment.

Utilize selected technique [number] times a day for[number] minutes. Observe the client for signs thatindicate that the desired effect has occurred. This couldinclude:

• Sigh• Relaxation in muscles• Slower, deeper breathing

Understanding the client’s cognitive map facilitates thedevelopment of interventions that facilitate clientchange.61,64

All these techniques have been demonstrated to haveeffects on the body’s energy fields.45,46,53,57,62–64

Application of these interventions by the nurse isrelated to having appropriate training in the technique.If the nurse is unskilled in the techniques, effortsshould be made for appropriate referrals at this point.Additional information on these techniques can befound in the references.

Increases the client’s level of comfort.55,64

Builds trust and promotes the client’s sense ofcontrol.55,64

Sound that is loud and irritating can have a negativeimpact on psychological and physiologic well-being.44

Odors have impact on the limbic system and impactaffect.

The nurse’s intention provides a crucial basis for theseinterventions.45,48,58

Changes that occur with alterations in the energy fieldsmay be perceived by the client before the practitionernotices a difference. The goal of these interventionsis to promote balance, so the treatment should stopwhen these differences are observed by the client orpractitioner.45,46,65 Also promotes the client’s sense ofcontrol.45,46

It is important that the client is well supported becausethe techniques do promote the relaxation response.

The ability of the client to maintain balance is based ongeneral levels of wellness, lifestyle, and stressors.65



••••••

Gerontic Health


Obtain medication profile (prescription and over-the-counter) to determine whether drug actions or reactionscontribute to the disturbance.

Ensure adequate padding and proper position for anysessions.

Adjust massage efforts and pressure to compensate forchanges in an older patient’s tactile sensation.

Use teaching materials, as needed, that are appropriatefor the patient (such as printed information of a sizethat is easily read, or quality audiotapes that are notdistorted or high pitched).

Discuss with the client use of complementary or alterna-tive therapies prior to initiating therapies.

Teach clients or caregivers relaxation strategies, use ofguided imagery, massage, or music therapies to pro-mote stress reduction.

Ensure that therapeutic touch sessions, if used, are ofbrief duration and gently done.

Medications may contribute to disturbed energy fields.

Proper positioning prevents pain, pressure, and thus dis-turbances in concentration.

Older adults, with aging changes in the nervous sys-tem, may have a decreased perception of beingtouched.

Uncompensated sensory changes of aging can affect theability to use audio–visual sources if the information isnot adjusted to meet the older adult’s needs.

Older adults may experience psychological or spiritualdistress if therapies used cause a conflict with theirbelief system. (Some adults may react negatively totherapeutic touch, perceiving it as “laying on of hands”in a religious manner.)70

The therapies listed are recommended for older adultswho would benefit from the reduced sympatheticresponse to stress. The physical and psychologicalchanges associated with aging can increase stress andimpede body/mind healing.63,71

Caution is recommended when using therapeutic touchwith infants, very debilitated patients, and the elderly.59


• Drop in voice volume• Peripheral flush on the face and neck• Client’s report of feeling different• Reassessment indicates balance has occurred

Assist the client into a comfortable, relaxed position aftertreatment.

Teach the client techniques that can maintain balancebetween treatments and that do not require the assis-tance of a practitioner, including:

• Relaxation• Cross crawl exercises• Stress reduction• Cognitive reframing• Visualization• Improved nutrition• Decreasing use of tobacco and alcohol

Note teaching schedule and content here.

Maintenance of energy field balance involves a holisticapproach to care and has been demonstrated to haveeffects on human energy fields.45–53,62,65–68




••••••

Home Health


Assist the client and family to identify disturbances inenergy field.

Teach the client and family techniques to prevent and/ortreat disturbed energy field, such as:

• Therapeutic touch• Foot or hand reflexology• Visual imagery• Visualization with relaxation techniques• TENS• Biofeedback

Assist the client and family in providing a private, quietenvironment.

Assist the client and family in identifying resources in thecommunity, such as:

• Massage therapist• Reflexologists• Stress reduction classes

Early identification assists in providing early intervention.

Involvement improves motivation and improves the out-come. Self-care is enhanced.

Client comfort is increased, and response to interventionis enhanced.61,67

Use of existing community services is efficient use ofresources.

HEALTH MAINTENANCE,INEFFECTIVE

DEFINITION44

Inability to identify, manage, and/or seek out help to main-tain health.


1. History of lack of health-seeking behavior2. Reported or observed lack of equipment, financial,

and/or other resources3. Reported or observed impairment of personal support

systems4. Expressed interest in improving health behaviors5. Demonstrated lack of knowledge regarding basic health

practices

6. Demonstrated lack of adaptive behaviors to internal orexternal environmental changes

7. Reported or observed inability to take responsibility formeeting basic health practices in any or all functionalpattern areas

RELATED FACTORS43

1. Lack of, or significant alteration in, communicationskills (written, verbal, and/or gestural)

2. Lack of ability to make deliberate and thoughtfuljudgments

3. Perceptual or cognitive impairment (complete or partiallack of gross and/or fine motor skills)

4. Ineffective individual coping5. Dysfunctional grieving6. Unachieved developmental tasks


Gerontic Health


Document older adult’s use of any complementary oralternative therapies, to include preferred treatment,frequency of treatments, and effects experienced.

Discuss with clients potential effects from complemen-tary or alternative therapies, such as dizziness or weak-ness after acupuncture, risk for fractures withchiropractic, and drug or herb interactions.

Many adults are reluctant to discuss use of alternativetherapies. Nondisclosure may lead to adverse reactionsfrom drug, food, or herb interactions.69,70

Little research is currently available on the effects ofcomplementary or alternative therapies on older adults.Cautioning clients on potential effects may reduce therisk for injury or adverse reactions.70


Health Maintenance, Ineffective 43

••••••


Spiritual DistressA problem in the Value-Belief Pattern could result invariance in health maintenance. If the therapeutic reg-imen causes conflict with cultural or religious beliefsor with the individual’s value system, then it is likelysome alteration in health maintenance will occur.Interviewing the patient regarding individual values,goals, or beliefs that guide personal decision makingwill assist in clarifying whether the primary diagnosisis Ineffective Health Maintenance or a problem in theValue-Belief Pattern.

Ineffective CopingEither Ineffective Individual Coping or Compromised orDisabled Family Coping could be suspected if thereare major differences between the patient and familyreports of health status, health perception, and health-care behavior. Ineffective Community Coping may bepresent if there are inadequate resources for problemsolving or deficits in social support services for com-munity members. Verbalizations by the patient or fam-ily member regarding inability to cope also indicateineffective coping. Community members may expressdissatisfaction with meeting community needs.

7. Ineffective family coping8. Disabling spiritual distress9. Lack of material resources


1. Dementias such as Alzheimer’s disease and multi-infarct2. Mental retardation3. Any condition causing an alteration in level of con-

sciousness, for example, a closed head injury, carbonmonoxide poisoning, or cerebrovascular accident

4. Any condition affecting the person’s mobility level,for example, hemiplegia, paraplegia, fractures, ormuscular dystrophy

5. Chronic diseases, for example, rheumatoid arthritis,cancer, chronic pain, or multiple sclerosis

EXPECTED OUTCOME

Will describe at least [number] contributing factors that leadto health maintenance alteration and at least one measure toalter each factor by [date].

TARGET DATES

Assisting patients to adapt their health maintenance requiresa significant investment of time and also requires close col-laboration with home health caregivers. For these reasons, itis recommended the target date be no less than 7 days fromthe date of admission.

Interrupted Family ProcessThrough observing family interactions and communi-cation, the nurse may assess that Interrupted FamilyProcess exists. Rigidity of family functions and roles,poorly communicated messages, and failure toaccomplish expected family developmental tasks area few observations to alert the nurse to this possiblediagnosis.

Activity Intolerance or Self-Care DeficitThe nursing diagnosis of Activity Intolerance or Self-Care Deficit should be considered if the nurseobserves or validates reports of inability to completethe required tasks because of insufficient energy orbecause of the patient’s inability to feed, bathe, toilet,dress, and groom him- or herself.

PowerlessnessThe nursing diagnosis of Powerlessness is consideredif the patient reports or demonstrates having littlecontrol over situations, expresses doubt about abilityto perform, or is reluctant to express his or her feel-ings to health-care providers.

Deficient KnowledgeDeficient Knowledge may exist if the patient or familyverbalizes less than adequate understanding of healthmanagement or recalls inaccurate health information.

Impaired Home MaintenanceThis diagnosis is demonstrated by the inability of thepatient or family to provide a safe living environment.


Adult Health


Assist the patient to identify factors contributing to healthmaintenance change through one-to-one interviewingand value clarification strategies. Factors may include:

Healthy living habits reduce risk. Assistance is oftenrequired to develop long-term change. Identification ofthe factors significant to the patient will provide thefoundation for teaching positive health maintenance.




••••••


Adult Health


• Stopping smoking53,71–74

• Ceasing drug and alcohol use• Establishing exercise patterns75

• Following good nutritional habits• Using stress management techniques• Using family and community support systems• Using over-the-counter medications• Using herb, vitamins, food supplements, or cleansing

programs76

Develop with the patient a list of assets and deficits ashe or she perceives them. From this list, assist thepatient in deciding what lifestyle adjustments willbe necessary.

Identify, with the patient, possible solutions, modifica-tions, etc., to cope with each adjustment.

Develop a plan with the patient that shows both short-term and long-term goals. For each goal, specify thetime the goal is to be reached.

Have the patient identify at least two support persons.Arrange for these persons to come to the unit andparticipate in designing the health maintenance plan.

Assist the patient and significant others in developing alist of potential strategies that will assist in the devel-opment of the lifestyle changes necessary for healthmaintenance. (This list should be a brainstormingprocess and include both solutions that appear to bevery unrealistic as well as those that appear most real-istic.) After the list is developed, review each item withthe patient, combining and eliminating strategies whenappropriate.

Develop with the patient a list of the benefits and disad-vantages of behavior changes. Discuss each item withthe patient as to the strength of motivation that eachitem has.

Develop a behavior change contract with the patient,allowing the patient to identify appropriate rewards andconsequences. Remember to establish modest goalsand short-term rewards. [Note reward schedule here.]

Teach the patient appropriate information to improvehealth maintenance (e.g., hygiene, diet, medicationadministration, relaxation techniques, and copingstrategies).

Review activities of daily living (ADLs) with the patientand support person. Incorporate these activities into thedesign for a health maintenance plan.

Increases the patient’s sense of control and keeps the ideaof multiple changes from being overwhelming.

The more the patient is involved with decisions, thehigher the probability that the patient will incorporatethe changes.

Avoids overwhelming the patient by indicating that notall goals have to be accomplished at the same time.

Provides additional support for patient in maintainingplan.

People most often approach change with “more of thesame” solutions. If the individual does not think thatthe strategy will have to be implemented, he or she willbe more inclined to develop creative strategies forchange.76

Placing items in priority according to the patient’s moti-vation increases probability of success.

Positive reinforcement enhances self-esteem and supportscontinuation of desired behaviors. This also promotespatient control, which in turn increases motivation toimplement the plan.55

Provides the patient with the basic knowledge needed toenact the needed changes.

Incorporation of usual activities personalizes the plan.

● N O T E : May have to either increase or decrease ADLs.



••••••

Assist the patient and support person to design a monthlycalendar that reflects the daily activities needed to suc-ceed in health maintenance.

Have the patient and support person return/demonstratehealth maintenance procedures at least once a day forat least 3 days before discharge. Times and types ofskills should be noted here.

Set a time to reassess with the patient and support personprogress toward the established goals. This should beon a frequent schedule initially and can then graduallydecrease as the patient demonstrates mastery. [Noteevaluation times here.]

Provide the patient with appropriate positive feedback ongoal achievement. Remember to keep this behaviorallyoriented and specific.

Communicate the established plan to the collaborativemembers of the health-care team.

Refer the patient to appropriate community health agen-cies for follow-up care. Be sure referral is made atleast 3 to 5 days before discharge.

Schedule appropriate follow-up appointments for patientbefore discharge. Notify transportation service andsupport persons of these appointments. Write appoint-ment on brightly colored cards for attention. Includedate, time, appropriate name (physician, physical thera-pist, nurse practitioner, etc.), address, telephone num-ber, and name and telephone number of person whowill provide transportation.

Provides a visual reminder.

Permits practice in a nonthreatening environment whereimmediate feedback can be given.

Provides an opportunity to evaluate and to give thepatient positive feedback and support for achievements.

Provides continuity and consistency in care.

Ensures the service can complete their assessment andinitiate operations before the patient is discharged fromthe hospital. Use of the network of existing communityservices provides for effective utilization of resources.

Facilitates patient’s keeping of appointments and rein-forces importance of health maintenance.

Child Health

● N O T E : Developmental consideration should always guide the health maintenanceplanned for the child patient. Also, identification of primary defects is stressed to reducethe likelihood of secondary and tertiary delays.


Determine who is the patient’s primary caregiver.

Teach the patient and family essential information toestablish and maintain health according to age, devel-opment, and status. Well checks are suggested at timeof immunization with access to a health-care providerfor annual checks or in time of illness after 1 year inthe absence of a chronic health-care need.

Assist the patient and family in designing a calendar tomonitor progress in meeting goals. Offer developmen-tally appropriate methods (e.g., toddlers enjoy stickersof favorite cartoon or book characters).

Fosters the likelihood for continuity of care and who isaccountable for care of child.

An individualized plan of care more definitively reflectsspecific health maintenance needs and increases thevalue of the plan to the patient and his or her family.

Reinforcement in a more tangible mode facilitates com-pliance with the plan of health maintenance, especiallywith long-term situations.





••••••


Child Health


Identify risk factors that will impact health-care mainte-nance (e.g., prematurity, congenital defects, alteredneurosensory functioning, errors of metabolism, oraltered parenting).

Begin to prepare for health maintenance on initial meet-ing with child and family.

Provide appropriate telephone numbers for health teammembers and clinics to the child and parents to assistin follow-up.

Identification of risk factors allows for more appropriateanticipatory planning of health care, assists in minimiz-ing crises and escalation of simple needs, and serves toreduce anxiety.

A holistic plan of care realistically includes futuristicgoals, not merely immediate health needs.

Anticipatory planning for potential need for communica-tion allows the patient or family realistic methods forassuming health care while enjoying the back-up ofresources.

Women’s Health


Assist the patient to describe her perception and under-standing of essential information related to her individ-ual lifestyle and the adjustment necessary to establishand maintain health in each cycle of reproductive life.

Develop with the patient a list of stress-related problemsat work and at home as she perceives them. From thislist, assist the patient in deciding what lifestyle adjust-ments will be necessary to establish and maintainhealth.

Cigarette smoking is not only detrimental to the health ofwomen, but it is also the causing factor involved withmorbidity and mortality. One in four women smokeand more than 3.1 million adolescents in America arecigarette smokers.78

Identify, with the patient, possible solutions andmodification to facilitate coping with adjustments.Develop a plan that includes short-term and long-term goals. For each goal, specify the time frame forreaching the goal.

Provide factual information to the patient about menstrualcycle patterns throughout the life span. Include prepu-bertal, menarcheal, menstrual, premenopausal,menopausal, and postmenopausal phases.81

Teach the patient how to record accurate menstrual cycle,obstetric, and sexual history. Assist the patient in rec-ognizing lifestyle changes that occur as a part of nor-mal development.

Allows assessment of the patient’s basic level of knowl-edge so that a plan can begin at the patient’s currentlevel of understanding.

Provides essential information to assist patient in plan-ning a healthy lifestyle.

Experts recommend following PHS (US Public HealthService: Treating Tobacco Use and DependencePractice Guidelines)79 guidelines, which recommendthree types of effective counseling and therapy79,80:• Skill training• Intra-treatment-clinician support• Extra-treatment-social support

Consider psychosocial elements of women’s lifestylewhen offering interventions to stop smoking. Augmentstrategies with specific information related to each lifecycle. (Adolescence, reproductive, mid-life, elder)78

Provides sequential steps to alternate health maintenancewithin a defined time period. Keeps the patient frombeing overwhelmed by all the changes that might benecessary.

Provides basic information and knowledge that is neededthroughout life span.

Provides the patient with the information necessary tocope with changes throughout the reproductive cycle.



••••••


Discuss pregnancy and the changes that occur duringpregnancy and childbearing. Stress the importanceof a physical examination before becoming pregnantto include a Pap smear, rubella titer, AIDS profile,and genetic workup (if indicated by family history).

Describe to and assist the patient in planning routines thatwill maintain well-being for the mother and fetus dur-ing pregnancy (e.g., reducing fatigue, eating a nutri-tionally adequate diet, exercising properly, obtainingearly prenatal care, and attending classes to obtaininformation about infant nutrition, infant care, and thebirthing experience).

Provide information and support during postpartumperiod to assist the new mother in establishing andmaintaining good infant nutrition, whether breastfeed-ing or formula feeding.

Refer the patient to appropriate groups for support andencouragement after birth of baby (e.g., La LecheLeague and parenting groups).

Teach terminology and factual information related tospontaneous abortion or the interruption of pregnancy.Encourage expression of feelings by the patient and herfamily. Provide referrals to appropriate support groupswithin the community.

Provide contraceptive information to the patient, includ-ing describing different methods of contraception andtheir advantages and disadvantages.

Emphasize the importance of lifestyle changes necessaryto cope with postmenopausal changes in the body, suchas estrogen replacement therapy, calcium supplements,balanced diet, exercise, and routine sleep patterns.

Teach the patient the importance of routine physicalassessment throughout the reproductive life cycle,including breast self-examination, Pap smears, androutine examinations by the health-care provider ofher choice (e.g., nurse midwife, nurse practitioner, orphysician).

Provides patient with the information needed to plan for ahealthy pregnancy.

Provides the expectant family with information to enablethem to make informed choices about pregnancy, child-birth, and beginning parenting.

Allows the patient to grieve and reduces fear regardingsubsequent pregnancies.

Allows the patient to plan appropriate contraceptivemeasures according to personal values and beliefs.

Provides the patient with basic information that willassist in planning a healthy lifestyle during and follow-ing menopause. Discuss use of alternative therapies forhormone replacement therapy.60,80–83

Provides knowledge that allows the patient to plan ahealthy lifestyle.

Mental Health


Spend 30 minutes once a day discussing client’s percep-tion of current situation and life/personal goals beforethe changes occurred:

• Use open-ended questions and reflective listening.• Let the client be the expert.• Do not provide advice.

Provide positive verbal reinforcement for the client’sstrengths and previous successes.

Behavior change that is developed with the client usingthe client’s identified needs and co-evolved solutionsimproves outcomes.84-86

Positive reinforcement increases behavior.87




••••••


Mental Health


Discuss client’s understanding of the options to facilitatethe identified changes. Reflect to client nurse’s under-standings of the client’s solutions and goals.Summarize the solutions and goals that the client iden-tified. Develop a schedule for positive reinforcementwhen goals are attained. [Note the reinforcers andschedule of reinforcement here.]

Discuss with client sources of social support:• Schedule meeting with client and social support sys-

tem. Note the date and time of that meeting here.• Spend 1 hour one time per week meeting with client

and social support system to focus on:• With client’s permission educate support system

about client’s health-care needs• Model communication and assist support system in

developing positive communication skills

Include the client in group therapy to provide positiverole models and peer support and to permit assessmentof goals and exposure to differing problem solutions.


Social support improves health outcomes.88

Group provides opportunities to relate and react to otherswhile exploring behavior with each other.87

Gerontic Health

● N O T E : Interventions provided in the adult health section are applicable to olderadults. The major emphasis here is on client education. Ageism may present barriers toteaching older clients. The older adult is capable of learning new information.89

Teaching strategies are available to enhance the learning experience for older adults.90


Ensure privacy, comfort, and rapport prior to teachingsessions.

Avoid presenting large amounts of information at onetime.

Monitor energy level as teaching session progresses.

Present small units of information, with repetition, andencourage patient to use cues that enhance ability torecall information.

Use multisensory approach to learning sessions wheneverpossible.

Reduces anxiety and promotes a non-distracting environ-ment to enhance learning.

This encourages increased opportunity to process andstore new information.

Reduces possibility of fatigue which can impair learning.

Compensates for delayed reaction time associated withaging. Promotes retention of information by connectinginformation to previously mastered skills.90

Hearing, vision, touch, and smell used in conjunction canstimulate multiple areas in the cerebral cortex to pro-mote retention.91

Home Health


Assist the client and family to identify home and work-place factors that can be modified to promote healthmaintenance (e.g., ramps instead of steps, eliminationof throw rugs, use of safety rails in showers, and main-tenance of a nonsmoking environment).92,93

This action enhances safety and assists in preventingaccidents. Promoting a nonsmoking environment helpsreduce the damaging effects of passive smoke.


Health-Seeking Behaviors (Specify) 49

••••••


Involve the client and family in planning, implementing,and promoting a health maintenance pattern through:

• Establish family conferences to discuss strategies formeeting client health maintenance needs.

• Engage in mutual goal setting with client and family.Plan strategies with the client/family to establish goalsfor their involvement in managing the therapeuticregimen.

• Assist family members in acquiring family or commu-nity based assistance for specified tasks as appropriate(e.g., cooking, cleaning, transportation, companionship,or support person for exercise program).

Teach the family and caregivers about disease manage-ment for existing illness:

• Symptom management• Medication effects, side effects, and interactions with

over-the-counter medications• Reporting the use of over-the-counter remedies, herbal

supplements and medicines to the health-care provider• Wound care as appropriate. Prevention of skin break-

down for clients with illnesses contributing to immo-bility.

Teach the client and family health promotion and diseaseprevention activities:

• Relaxation techniques• Nutritional habits to maintain optimal weight and phys-

ical strength• Techniques for developing and strengthening support

networks (e.g., communication techniques or mutualgoal setting)

• Physical exercise to increase flexibility, cardiovascularconditioning, and physical strength and endurance94

• Evaluation of occupational conditions94

• Control of harmful habits (e.g., control of substanceabuse)

• Therapeutic value of pets95

Involvement improves motivation and outcomes.

Provides a sense of autonomy and prevents prematureprogression of illness.

These activities promote a healthy lifestyle.

HEALTH-SEEKINGBEHAVIORS (SPECIFY)

DEFINITION44

A state in which an individual in stable health is activelyseeking ways to alter personal health habits and/or theenvironment in order to move toward a higher level ofhealth.


1. Expressed or observed desire to seek a higher level ofwellness

2. Demonstrated or observed lack of knowledge of healthpromotion behaviors

3. Stated (or observed) unfamiliarity with wellness com-munity resources

4. Expression of concern about impact of current environ-mental conditions on health status

5. Expressed or observed desire for increased control ofhealth practice

RELATED FACTORS44

To be developed.


Because this diagnosis, as indicated by the definition, relatesto individuals in stable health, there are no related medicaldiagnoses.



••••••


Adult Health


Two hours after admission, identify post-dischargeresources (e.g., classes, support groups) to reinforcepositive health habits.

Note potential risk factors that should be dealt withregarding actual health status (e.g., financial status,coping strategies, or resources).

Teach the patient about activities for promotion of healthand prevention of illness (e.g., well-balanced diet,including restricted sodium and cholesterol intake, needfor adequate rest and exercise, effects of air pollutantsincluding smoking, and stress management techniques).

Review the patient’s problem-solving abilities, and assistthe patient to identify various alternatives, especially interms of altering his or her environment.

Provide appropriate teaching to assist the patient andfamily in becoming confident in self-seeking health-care behavior (e.g., teach assertiveness techniques tothe patient and family).

Assist the patient and family to list benefits of high-levelwellness and health-seeking behavior.

Help the patient and family develop a basic written planfor achieving individual high-level wellness. Providetime for questions before dismissal to solidify plans forfollow-up care. At a minimum, 30 minutes per day for2 days prior to discharge should be allowed for thisquestion-and-answer period. Note times here.

Give and review pamphlets about wellness communityresources.

Support the patient in his or her health-seeking behavior.Advocate when necessary.

Refer to appropriate health-care providers and variouscommunity groups as appropriate for assistance neededby the patient and his or her family.

Allows adequate time to complete discharge planning andteaching required for home care.

Provides basic knowledge that will contribute to individu-alized discharge planning.

Provides the patient and family with the essential knowl-edge needed to modify behavior.

Promotes shared decision making and enhances patient’sfeeling of self-control.

Increases sense of self-control and reduces feelings ofpowerlessness.

Makes visible the reasons these activities will help thefamily.

Demonstrates importance of follow-up care.

Reinforces teaching and provides ready reference forpatient and family after discharge from agency.

Provides supportive environment and underlines theimportance of health-seeking activities.

Provides professional support systems that can assist inhealth-seeking behavior.


Impaired Home MaintenanceThis diagnosis may be involved if the individual orfamily is unable to independently maintain a safe,growth-promoting immediate environment.

PowerlessnessIf the client expresses the perception of lack ofcontrol or influence over the situation and potentialoutcomes or does not participate in care or decisionmaking when opportunities are provided, the diag-nosis of Powerlessness should be investigated.Community powerlessness may be an indicator ofIneffective Community Coping.

EXPECTED OUTCOME

Will [increase/decrease] [habit] by [amount] by [date].

E X A M P L E S

Will decrease smoking by 75 percent by [date].Will increase exercise by walking 2 miles three times

per week by [date].

TARGET DATES

Changing a habit involves a significant investment of timeand energy regardless of whether the change involves start-ing a new habit or stopping an old one. Therefore, the targetdates should be expressed in terms of weeks and months.



••••••

Child Health


Monitor the child and family for perceived value ofhealth. Incorporate into any plan personal and familyneeds identified through this monitoring.

Assist the child and family to identify appropriate healthmaintenance needs and resources (e.g., immunizations,nutrition, daily hygiene, basic safety, how to obtainmedical services when needed [including health educa-tion], how to take temperature of an infant, basic skillsand care for health problems, health insurance,Medicaid, and related state resources).

Values are formulated in the first 6 years of life and willserve as primary factors in how health is perceived andenjoyed by the individual and family. If values are inquestion, there is greater likelihood that how health tobe maintained will be subject to this values conflict.Until health-seeking behavior is identified as a value,follow-up care will not be deemed to be beneficial.

Knowing available resources and incorporating theseresources into the plan for health care facilitate long-term attention to health.

Women’s Health


Teach the patient the importance of seeking informationand support during the reproductive life cycle. Includeinformation about prepubertal, menarcheal, menstrual,childbearing, parenting, menopausal, and post-menopausal periods of the life cycle.

Provide woman with information about health tests andscreenings at various life stages. These tests include:

• Blood glucose• Blood pressure• Bone density test (osteoporosis)• Breast cancer screenings• Cardiovascular disease risk assessment• Cholesterol• Colorectal exam• Dental checkup• Eye exam• Hearing test• Pap test and pelvic exam• Routine physical• Thyroid screening

Provides the basic information needed to support health-seeking behaviors.

Most chronic diseases that affect women can be pre-vented. Knowing the risk factors and the modifyingbehaviors can greatly reduce the number of womenfacing chronic illness and even death. Cardiac diseaseis the number one killer of women in this country.Research has shown that most morbidity and mortalityof women can be greatly decreased by routing screen-ing, diagnosis, counseling and behavior modification.96

Mental Health


Assign the client a primary care nurse. Provides increased individuation and continuity of care,facilitating the development of a therapeutic relation-ship. The nursing process requires that a trusting andfunctional relationship exist between nurse and client.61




••••••


Mental Health


Primary care nurse will spend 30 minutes twice a daywith client [note times here]. The focus of these inter-actions will conform to the following schedule:

• Interaction 1: Have the client identify specific areas ofconcern. List the identified concerns on the care plan.Also identify the primary source of this concern (i.e.,client, family member, member of the health-care team,or other members of the client’s social system).

• Interaction 2: List specific goals for each concern theclient has identified. These goals should be achievablewithin a 2- to 3-day period. (One way of setting realis-tic, achievable goals is to divide the goal described bythe client by 50 percent.)

• Interaction 3: Have the client identify steps that havebeen previously taken to address the concern.

• Interaction 4: Determine the client’s perceptions ofabilities to meet established goals and areas where assis-tance may be needed. (If the client indicates a perceptionof inability to pursue goals without a great deal of assis-tance, the alternative nursing diagnoses of Powerlessnessand Knowledge Deficit may need to be considered.)

Assist client in developing strategies to achieve the estab-lished goals, developing action plans, evaluating theoutcome of these plans, and then revising futureactions in future interactions. [Note schedule of theseinteractions here.]

Provide positive verbal reinforcement for client’s achieve-ments of goals. This reinforcement should be specificto the client’s goals. [Note those things that are reward-ing to the client here and the kind of behavior to berewarded.]

Promotes the client’s trust in the nurse and perception ofcontrol.85–87

Promotes the client’s perception of control.

Promotes the client’s self-esteem when goals can beaccomplished.87

Promotes the client’s self-esteem and provides motivationfor continued efforts.

Gerontic Health

In addition to interventions for Adult Health, the following may be used with the older client:


Encourage the client to participate in health-screeningand health-promotion programs such as SeniorWellness Programs. These programs are often offeredby hospitals, clinics, and senior citizens centers.




Present small units of information, with repetition, andencourage patient to use cues that enhance ability torecall information.

Provides a cost-effective, easily accessible, long-termsupport mechanism for the patient.

Reduces anxiety and promotes a nondistracting environ-ment to enhance learning.






••••••

Home Health


Help the client identify his or her personal definitionof health, perceived personal control, perceived self-efficacy, and perceived health status.

Assist the client in identifying required lifestyle changes.Assist the client to develop potential strategies thatwould assist in the lifestyle changes required.

Assist the client and family to identify home and work-place factors that can be modified to promote healthmaintenance (e.g., ramps instead of steps, eliminationof throw rugs, use of safety rails in showers, and main-tenance of a nonsmoking environment).74,89,90


• Helping to establish family conferences to discussstrategies for meeting client health maintenance needs.

• Engaging in mutual goal setting with client and family.Encourage the client/family to establish goals for theirown involvement in managing the therapeutic regimen.

• Assisting family members in acquiring family orcommunity-based assistance for specified tasks asappropriate (e.g., cooking, cleaning, transportation, com-panionship, or support person for exercise program)

Teach the family and caregivers about disease manage-ment for existing illness:


over-the-counter medications• Reporting the use of over-the-counter remedies, herbal

supplements and medicines to the health-care provider• Wound care as appropriate. Prevention of skin breakdown

for clients with illnesses contributing to immobility.


• Relaxation techniques• Nutritional habits to maintain optimal weight and physi-

cal strength• Techniques for developing and strengthening support

networks (e.g., communication techniques or mutualgoal setting)

• Physical exercise to increase flexibility, cardiovascularconditioning, and physical strength and endurance

• Evaluation of occupational conditions• Control of harmful habits (e.g., control of substance

abuse)• Therapeutic value of pets95

Awareness of definition of health, locus of control, per-ceived efficiency, and health status identifies potentialfacilitators and barriers to action.

Lifestyle changes require change in behavior. Self-evaluation and support facilitate these changes.









INFECTION, RISK FOR

DEFINITION44

The state in which an individual is at increased risk for beinginvaded by pathogenic organisms.

DEFINING CHARACTERISTICS(RISK FACTORS)44

1. Invasive procedures2. Insufficient knowledge to avoid exposure to pathogens3. Trauma4. Tissue destruction and increased environmental expo-

sure5. Rupture of amniotic membranes6. Pharmaceutical agents7. Malnutrition8. Immunosuppression9. Inadequate secondary defenses (e.g., decreased hemo-

globin, leukopenia, suppressed inflammatory response)10. Inadequate acquired immunity11. Inadequate primary defenses (broken skin, traumatized

tissue, decrease in ciliary action, stasis of body fluids,change in pH secretions, altered peristalsis)

12. Chronic disease

••••••54 Health Perception–Health Management Pattern


Adult Health


Monitor vital signs every 4 hours around the clock. [Statetimes here.]

Use standard precautions and teach the patient and familythe purpose and techniques of standard precautions.98

Teach the patient and family about the infectious process,routes, pathogens, environmental and host factors, andaspects of prevention.

Provides a baseline that allows quick recognition of devi-ations in subsequent measurements.

Protects the patient and family from infection.

Provides basic knowledge for self-help and self-protection.


Self-Care DeficitSelf-Care Deficit, especially in the areas of toileting,feeding, and bathing-hygiene, may need to be con-sidered if improper handwashing, personal hygiene,toileting practice, or food preparation and storagehave increased the risk of infection.

Impaired Skin Integrity; Impaired TissueIntegrity; Imbalanced Nutrition, Less ThanBody Requirements; Impaired Oral MucousMembraneThese diagnoses may predispose the client toinfection.

RELATED FACTORS44

The risk factors serve also as the related factors.


1. AIDS2. Burns3. Chronic obstructive pulmonary disease (COPD)4. Diabetes mellitus5. Any surgery and any condition where steroids are used

as a part of the treatment regimen6. Substance abuse or dependence7. Premature rupture of membranes

EXPECTED OUTCOME

Will return/demonstrate measures to decrease the risk forinfection by [date].

TARGET DATES

An appropriate target date would be within 3 days from thedate of diagnosis.

Impaired Physical MobilityThis diagnosis should be considered if skin break-down is secondary to lack of movement. Skin break-down always predisposes the patient to Risk forInfection.

Imbalanced Body Temperature; HyperthermiaThese diagnoses should be considered when thebody temperature increases above normal, which iscommon in infectious processes.

Ineffective Management of TherapeuticRegimen (Noncompliance)This diagnosis may be occurring in cases of inappro-priate antibiotic usage or inadequate treatment ofwounds or chronic diseases.


Infection, Risk For 55

••••••

Maintain adequate nutrition and fluid and electrolyte bal-ance. Provide a well-balanced diet with increasedamounts of vitamin C, sufficient iron, and 2400 to2600 mL of fluid daily.

Collaborate with the physician regarding screening speci-mens for culture and sensitivity (e.g., blood, urine, spu-tum, and spinal fluid).

Monitor the administration of antibiotics for maintenanceof blood levels and for side effects (e.g., diarrhea ortoxicity).

Maintain a neutral thermal environment.

Assist the patient with a thorough shower at least oncedaily (dependent on age) or total bed bath daily.

Provide good genital hygiene, and teach the patient howto care for the genital area.

Wash your hands thoroughly between each treatment.Teach the patient the value of frequent handwashing.

Use sterile technique when changing dressings or per-forming invasive procedures.

Turn every 2 hours on [odd/even] hour.Perform passive exercises or have the patient perform

active range of motion (ROM) exercises every 2 hourson [odd/even] hour. Remember that the patient mayhave decreased tolerance of activity.

Cough and deep-breathe every 2 hours on [odd/even]hour.

Consult with appropriate assistive resources as indicated.

Helps prevent disability that would predispose infection.

Allows accurate determination of the causative organismand identification of the antibiotic that will be mosteffective against the organism.

Antibiotics have to be maintained at a consistent bloodlevel, usually 7–10 days, to kill causative organisms.Antibiotics may destroy normal bowel flora, predispos-ing the patient to the development of diarrhea andincreasing the chance of infection in the lower gas-trointestinal tract.

Avoids overheating or overcooling of room that wouldcontribute to complications for the patient.

Reduces microorganisms on the skin.

Also enhances feeling of well being, and prevents spreadof opportunistic infections.97,99

Prevents cross-contamination and nosocomial infections.

Protects the patient from exposure to pathogens.100

Promotes tissue perfusion.

Mobilizes static pulmonary secretions, thereby improvinggas exchange.

Appropriate use of existing community service is effi-cient use of resources.

Child Health


Assess for all contributing factors to include pharmaco-logic agents, recent exposures, and deviations inimmune status.

Monitor axillary temperature every 2 hours on [odd/even]hour. (May be assessed per rectal or tympanic accord-ing to health-care provider’s preference.)

Institute aseptic precautions.Provide instructions to child at developmentally appropri-

ate level and to parents while instituting infectious pre-cautions as applicable.

If neutropenic precautions are necessary, monitor CBCand absolute neutrophil count.

Obtain specimens as required, esp. blood, urine, and stool.(May require lumbar puncture for septic work-up.)

Widest consideration will likely identify how the threat ofinfection will be met.

Most appropriate route for frequent measurements for thevery young child. Oral temperature measurementswould not be accurate.

Provides basis for decreased likelihood of reinfection.Allows for meeting child’s needs for understanding as

questions are answered. This helps to insure appropri-ate precautions are upheld to prevent spread to othersincluding family members.

Provides essential basis for diagnosis and treatment.

Ensures baseline and follow-up monitoring for adequacyof treatment/status.





••••••

Women’s Health


During prenatal period, inform the mother about and howto prevent perinatal infections:

• Encourage the mother to avoid frequent changing ofpartners and other high-risk sexual behaviors whilepregnant.

Teach the mother good preventive health-care behaviorssuch as:

• Maintaining good nutrition• Teach strategies that allow women to gain and utilize

maximum energy by eating nutritiously, includingidentifying supplements that can augment energylevels.

• Perform a dietary assessment and provide a nutri-tional education to the breastfeeding woman.

• Getting correct amount of sleep• Exercise• Reducing stress levels

Test the mother for presence of TORCH infections.

In the presence of ruptured amniotic membranes, monitorfor signs of infection at least every 4 hours at [statetimes here] (e.g., elevated temperature or vaginal dis-charge odor).

Use aseptic technique when performing vaginal examina-tions, and limit the number of vaginal examinationsduring labor.

Infections acquired during pregnancy can cause signifi-cant morbidity and even mortality for both motherand/or infant.29

Pregnancy is considered an immunosuppressed state.Responses of the immune system during pregnancymay decrease the mother’s ability to fight infection.

Researchers agree that strong links exist between goodnutrition and the prevention of diseases such as osteo-porosis, cardiac disease, and certain female cancers. Infact, nutrition is one of the biggest factors in women’shealth throughout all the stages of her life.101,102

The recommended energy intake during the first 6 monthsof lactation can be reached by having one extra mealper day (approximately 500 kcal).103

This is a group of organisms that cross the placenta andinterfere with the development of the fetus and healthof the newborn infant.

Toxoplasmosis, Hepatitis B, Rubella, Cytomegalovirus,Herpes. Other infections such as Chlamydia, Group BStreptococcus, Syphilis, HIV and AIDS are also ofgreat concern as all of these infections have conse-quences for not only the pregnancy but also thenewborn.29

Provides clinical data needed to quickly recognize thepresence of infection.

Reduces the opportunities to introduce infection.


Child Health


Administer medications as scheduled with attention toappropriate dosage for weight/indication, peak andtrough results, and potential for allergenic response.

Encourage the child and parents to verbalize fears, con-cerns, or feelings related to infection by scheduling atleast 30 minutes per shift to counsel with family. Notetimes here.

Abides by safe practice of administration of medicationswithin desired blood levels.

Monitoring for side effects yields likelihood of earlydetection to lessen severity of possible anaphylaxis.

Provides support, decreases anxiety and fears, and pro-vides teaching opportunity.


Infection, Risk For 57

••••••

Teach the mother to take only showers (no tub baths) andto monitor and record temperature. Have her take tem-perature at least every 4 hours on a set schedule.

Keep linens and underpads clean and changed as neces-sary during labor.

Monitor incisions (cesarean section or episiotomy) atleast every 4 hours at [state times here] for redness,drainage, oozing, hematoma, or loss of approximation.

During postpartum period, monitor fundal height at leastevery 4 hours at [state times here] around the clock for48 hours.

During postpartum period, monitor the patient at leastevery 4 hours at [state times here] for any signs of foulsmelling lochia, uterine tenderness, or increased tem-perature.

In instances of abortion, obtain a complete obstetrichistory.

Monitor abdomen at least every 4 hours at [state timeshere] for any swelling, tenderness, or foul-smellingvaginal discharge following an abortion.

If meconium is present in amniotic fluid, immediatelyclear airway of the infant by suctioning (preferablydone by physician immediately on delivery of theinfant’s head).

Suction gastric contents immediately. Observe for sternalretractions, grunting, trembling, jitters, or pallor. If anyof these signs are present, notify the physician at once.

Wash hands each time before and after you handle thebaby.

Avoid wearing sharp jewelry that could scratch the baby.

Keep umbilical cord clean and dry by cleansing at eachdiaper change or at least every 2 hours on [odd/even]hour.

Monitor circumcision site for swelling, odor, or bleedingeach diaper change or at least every 2 hours on[odd/even] hour.

Demonstrate and have parent return/demonstrate:• How to take the baby’s temperature measurement• How to properly care for umbilical cord and

circumcision

Teaches the patient basic information to recognize andprevent infection.

Reduces the likelihood of nosocomial infections.


Provides database necessary to screen for infection.


Helps prevent aspiration pneumonia in the infant.

Indicates development of respiratory complications sec-ondary to meconium.

Prevents development of nosocomial infections.

Gives parents basic information regarding preventionof infection and monitoring for the development ofinfection.

Mental Health


Monitor the temperature of clients receiving antipsychoticmedications twice a day, and report any elevations tophysician. [Note times for temperature measurementhere.]

These clients are at risk for developing agranulocytosis.The greatest risk is 3 to 8 weeks after therapy hasbegun. Can occur any time during the first 12 weeksof treatment.104





••••••


Mental Health


Monitor the client for the presence of a sore throat in theabsence of a cold or other flu-like symptoms, mouthsores, skin ulcerations, and peripheral edema at leastdaily. Report any occurrence. Note schedule for thisassessment here.

Teach the client to report any signs of infection (lethargy,weakness, fever, sore throat, temperature elevations)symptoms to their health-care team.

During the first 12 weeks of treatment with an antipsy-chotic, report any signs of infection in the client to thephysician for assessment of white cell count.

Review the client’s CBC or WBC before antipsychoticsare started, and report any abnormalities on this andany subsequent CBCs to the physician.

Teach client and support systems about special WBCmonitoring programs (i.e., Clozapine requires amonthly WBC monitoring during the first 6 monthsand after 6 months every other week).

Teach the client and family handwashing techniques,nutrition, appropriate antibiotic use, hazards of sub-stance abuse, and universal precautions.

These could be symptoms of agranulocytosis.104

Provides a baseline for comparison after the client hasbegun antipsychotic therapy.

These measures can help prevent or decrease the risk ofinfection.

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized:


Encourage clients to maintain immunization status, espe-cially annual influenza, tetanus and diphtheria every10 years, and annual pneumonia vaccine.

Teach importance of avoiding crowds in the presence offlu or cold outbreaks.

Teach the client and caregiver atypical signs and symp-toms that may indicate infection in an older adult.

Assist the client in maintaining adequate hydration of2000 cc daily.

Assist the client in maintaining adequate vitamin intake,particularly vitamins A, C, and E; zinc; and selenium.

Older adults, with aging changes to the immune system,are at increased risk for infection.

Decreases potential for contact with infectious processesat high-risk times.

Older adults may not have fever, localized pain, or otherclassic signs in the presence of infection.

Adequate hydration status has a preventive effect.

These nutrients are known to assist in infectionprevention.

Home Health


Teach the client and family measures to prevent transmis-sion of infectious disease to others. Assist the patientand family with lifestyle changes that may be required:

• Handwashing• Isolation as appropriate

Many infectious diseases can be prevented by appropriatemeasures. The client and family members require thisinformation and the opportunity to practice these skills.


Injury, Risk For 59

••••••

• Proper disposal of infectious waste (e.g., bagging)• Proper treatment of linens soiled with infectious matter.• Proper use of disinfectants• Appropriate medical intervention (e.g., antibiotics or

antipyretics)• Immunization as recommended by CDC• Signs and symptoms of infection• Treatment for lice and removal of nits• Asepsis for wound care

Hot water provides an effective means of destroyingmicroorganisms, and a temperature of at least 160� Ffor a minimum of 25 minutes is commonly recom-mended for hot-water washing. Chlorine bleach pro-vides an extra margin of safety. A total availablechlorine residual of 50 to 150 ppm is usually achievedduring the bleach cycle.98,105–107

● N O T E : Items can be sterilized at home by immersing in boiling water for 10 min-utes. The water needs to be boiling for the entire 10 minutes. Equipment, such as bed-side commodes, bedpans, and other items exposed to blood and body fluids can alsobe cleaned with a 1:10 bleach and water solution.

Participate in tuberculosis screening and preventionprogram.108–110

Monitor for factors contributing to the risk forinfection.

Involve the client and family in planning, implementing,and promoting reduction in the risk for infection:

• Family conference• Mutual goal setting• Communication

Teach the client and family measures to prevent ordecrease potential for infection:

• Handwashing techniques, including the use of alcohol-based antimicrobial gels.

• Universal precautions for blood and body fluids• Personal hygiene and health habits• Nutrition• Immunization schedule• Proper food storage and preparation• Elimination of environmental hazards such as rodents

or insects• Proper sewage control and trash collection• Appropriate antibiotic use to include instruction to take

the entire prescribed dose, to refrain from using par-tially used prescriptions or prescriptions written forother persons.

• Hazards of substance abuse• Preparation and precautions when traveling to areas in

which infectious diseases are endemic• Signs and symptoms of infectious diseases for which

the client and family are at risk• Preparation for disaster (water storage, canned or dried

food, and emergency waste disposal)

This action serves as the database to identify the need forinterventions to prevent infections.

Family involvement is important to ensure success.Communication and mutual goals improve theoutcome.

These measures reduce the risk of infection.

INJURY, RISK FOR

DEFINITIONS44

Risk for Injury A state in which the individual is atrisk of injury as a result of environmental conditions inter-acting with the individual’s adaptive and defensive resources.

Risk for Suffocation Accentuated risk of accidentalsuffocation (inadequate air available for inhalation).

Risk for Poisoning Accentuated risk of accidentalexposure to or ingestion of drugs or dangerous products indoses sufficient to cause poisoning.

Risk for Trauma Accentuated risk of accidental tissueinjury, for example, wound, burn, or fracture.




••••••


A. Risk for Injury1. External

a. Mode of transport or transportationb. People or provider: Nosocomial agents; staffing

patterns; cognitive, affective, and psychomotorfactors

c. Physical: Design, structure, and arrangement ofcommunity, building, and/or equipment

d. Nutrients: Vitamins, food typese. Biologic: Immunization level of community,

microorganismf. Chemical: Pollutants, poisons, drugs, pharmaceuti-

cal agents, alcohol, caffeine, nicotine, preservatives,cosmetics, and dyes

2. Internala. Psychological: Affective, orientationb. Malnutritionc. Abnormal blood profile: Leukocytosis–leukopenia,

altered clotting factors, thrombocytopenia, sicklecell, thalassemia, decreased hemoglobin

d. Immuno–autoimmune dysfunctione. Biochemical, regulatory function: Sensory dysfunc-

tion, integrative dysfunction, effector dysfunction,tissue hypoxia

f. Developmental age: Physiologic, psychosocialg. Physical: Broken skin, altered mobility

B. Risk for Suffocation1. External (environmental)

a. Vehicle warming in closed garageb. Use of fuel-burning heater not vented to outsidec. Smoking in bedd. Children playing with plastic bags or inserting

small objects into their mouth or nosee. Propped bottle placed in an infant’s cribf. Pillow placed in an infant’s cribg. Eating large mouthfuls of foodh. Discarded or unused refrigerators or freezers with-

out removed doorsi. Children left unattended in bathtubs or poolsj. Household gas leaksk. Low-strung clotheslinel. Pacifier hung around infant’s head

2. Internal (individual)a. Reduced olfactory sensationb. Reduced motor abilitiesc. Cognitive or emotional difficultiesd. Disease or injury processe. Lack of safety educationf. Lack of safety precautions

C. Risk for Poisoning1. External (environmental)

a. Unprotected contact with heavy metals orchemicals

b. Medicines stored in unlocked cabinet accessible tochildren or confused persons

c. Presence of poisonous vegetationd. Presence of atmospheric pollutantse. Paint, lacquer, etc. in poorly ventilated areas or

without effective protectionf. Flaking, peeling paint or plaster in presence of

young childreng. Chemical contamination of food and waterh. Availability of illicit drugs potentially contaminated

by poisonous additivesi. Large supplies of drugs in housej. Dangerous products placed or stored within the

reach of children or confused persons2. Internal (individual)

a. Verbalization of occupational setting without ade-quate safeguards

b. Reduced visionc. Lack of safety or drug educationd. Lack of proper precautione. Insufficient financesf. Cognitive or emotional difficulties

D. Risk for Trauma1. External (environmental)

a. Slippery floors (e.g., wet or highly waxed)b. Snow or ice collected on stairs, walkwaysc. Unanchored rugsd. Bathtub without handgrip or antislip

equipmente. Use of unsteady ladders or chairsf. Entering unlighted roomsg. Unsteady or absent stair railsh. Unanchored electric wiresi. Litter or liquid spills on floors or stairwaysj. High bedsk. Children playing without a gate at the top of the

stairsl. Obstructed passageways

m. Unsafe window protection in homes with youngchildren

n. Inappropriate call-for-aid mechanisms for bed-resting patient

o. Pot handles facing toward front of stovep. Bathing in very hot water (e.g., unsupervised

bathing of young children).q. Potential igniting gas leaksr. Delayed lighting of gas burner or ovens. Experimenting with chemical or gasolinet. Unscreened fires or heatersu. Wearing plastic apron or flowing clothes around

open flamev. Children playing with matches, candles, cigarettesw. Inadequately stored combustibles or corrosives

(e.g., matches, oily rags, lye)x. Highly flammable children’s toys or clothingy. Overloaded fuse boxes


Injury, Risk For 61

••••••

z. Contact with rapidly moving machinery, indus-trial belts, or pulleys

aa. Sliding on coarse bed linen or struggling withinbed restraints

bb. Faulty electrical plugs, frayed wires, or defectiveappliances

cc. Contact with acids or alkalisdd. Playing with fireworks or gunpowderee. Contact with intense coldff. Overexposure to sun, sunlamps, or radiotherapygg. Use of cracked dinnerware or glasseshh. Knives stored uncoveredii. Guns or ammunition stored unlockedjj. Large icicles hanging from roofkk. Exposure to dangerous machineryll. Children playing with sharp-edged toys

mm. High-crime neighborhood and vulnerable clientsnn. Driving a mechanically unsafe vehicleoo. Driving after partaking of alcoholic beverages or

drugspp. Driving at excessive speedqq. Driving when tiredrr. Driving without necessary visual aidss. Children riding in the front seat in cartt. Smoking in bed or near oxygenuu. Overloaded electrical outletvv. Grease waste collected on stoves

ww. Use of thin or worn potholdersxx. Misuse of necessary headgear for motorized

cyclists or young children carried on adult bicy-cles

yy. Unsafe road or road-crossing conditionszz. Play or work near vehicle pathways (e.g., drive-

ways, laneways, or railroad tracks)aaa. Nonuse or misuse of seat restraints

2. Internal (individual)a. Lack of safety educationb. Insufficient finances to purchase safety equipment

or effect repairsc. History of previous traumad. Lack of safety precautionse. Poor visionf. Reduced temperature or tactile sensationg. Balancing difficultiesh. Cognitive or emotional difficultiesi. Reduced large or small muscle coordinationj. Weaknessk. Reduced hand–eye coordination

RELATED FACTORS44

The risk factors serve as the related factors for riskdiagnoses.


1. AIDS2. Dementias such as Alzheimer’s disease or multi-infarct

3. Diseases of the eye such as cataracts or glaucoma4. Medications, for example, hallucinogens, barbiturates,

opioids, or benzodiazepines5. Epilepsy6. Substance abuse or dependence


Activity IntoleranceThis diagnosis should be considered if the nurseobserves or validates reports of the patient’s inabilityto complete required tasks because of insufficientenergy. Insufficient energy could lead to accidentsthrough, for example, falling or dropping of items.

Impaired Physical MobilityThis diagnosis is appropriate if the patient has diffi-culty with coordination, range of motion, musclestrength and control, or activity restrictions related totreatment. This could be manifested by the frequentoccurrence of accidents or injury.

Deficient KnowledgeThis diagnosis may exist if the client or family verbal-izes less-than-adequate understanding of injury pre-vention.

Impaired Home MaintenanceThis diagnosis is demonstrated by the inability of thepatient or the family to provide a safe living environ-ment.

Disturbed Thought ProcessThis diagnosis should be considered if the patientexhibits impaired attention span; impaired ability torecall information; impaired perception, judgment, anddecision making; or impaired conceptual reasoningabilities. This diagnosis could certainly be reflected inincreased accidents or injuries.

Risk for ViolenceThis diagnosis exists if the accidents or injuries canbe related to the risk factors for self-inflicted or other-directed physical trauma (e.g., self-destructive behav-ior, substance abuse, rage, and hostile verbalizations).

EXPECTED OUTCOME

Will identify hazards [list] contributing to risk for injury andat least one corrective measure [list] for each hazard by[date].

TARGET DATES

Although preventing injury may be a lifelong activity, estab-lishing a mindset to avoid injury can be begun rapidly. Anappropriate target date would be within 3 days of admission.



••••••


Adult Health


Keep bed wheels locked and bed in low position. Keephead of bed elevated at least 30 degrees at all times.Utilize siderails as necessary

Assess patient safety status at least hourly. If risk forinjury exists, do not leave patient unattended. Schedulesitters around the clock. Provide appropriate signage orcommunication if the patient has been identified asbeing at risk for injury (e.g., falls).

Check respiratory rates and depth and chest sounds atleast every 4 hours at [Note times here].

Continuously assess airway patency. Know location ofemergency airway equipment.

Do not leave medications or solutions in the room.Make sure handrails are in place in the bathroom and that

safety strips are in tub and shower. Do not leave patientunattended in bathtub or shower.

Keep the patient’s room free of clutter.Orient the patient to time, person, place, and environment

at least once a shift and as necessary.

Provide night light.

Assist in correcting, to the extent possible, anysensory–perceptual problems through appropriatereferrals.

Assist the patient with all transfer and ambulation. If thepatient requires multiple pillows for rest or positioning,tape the bottom layer of pillows to prevent dislodging.

Teach the patient and family safety measures for use athome:

• Use nonskid rugs or tack down throw rug.• Use handrails.• Install ramps.• Use color contrast for steps, door knobs, electrical out-

lets, and light switches.• Avoid surface glare (e.g., floors or table tops). Maintain

clean, nonskid floors and keep rooms and halls free ofclutter.

• Change physical position slowly.• Use covers for electrical outlets.• Position pans with handles toward back of stove.• Have family post poison control number for ready ref-

erence.• Provide extra lighting in room and night light.

Teach the patient and significant other:• Alterations in lifestyle that may be necessary (e.g.,

stopping smoking, stopping alcohol ingestion, decreas-ing or ceasing drug ingestion, or ceasing driving)

• Use of assistive devices (e.g., walkers, canes, crutches,or wheelchairs)

Siderails should be used judiciously. Use alternativemethods in patients to whom side rails pose more of adanger (e.g., confused).

Primary preventive measures to ensure patient safety.Green dot serves to alert other health-care personnel ofpatient’s status.

Ongoing monitoring of risk factors.

Basic safety measures to prevent poisoning.Basic safety measures to prevent injury.

Basic safety measures to prevent injury.Keeps patient aware of environment.

Safety measure to prevent falling at night.

Correction of sensory–perceptual problems (vision, forexample) will assist in accident prevention.

Assists in preventing suffocation or tripping on pillows.

Basic safety measures.


Injury, Risk For 63

••••••

• Heimlich maneuver• Cardiopulmonary resuscitation (CPR)• Recognition of signs and symptoms of choking and

carbon monoxide poisoning• Necessity of chewing food thoroughly and cutting food

into small bites

Refer to appropriate agency for safety check of home.Make referral at least 3 days prior to discharge.

Allows time for checking and correction of problemareas.

Child Health


Maintain appropriate supervision of the infant at alltimes. Allow respite time for the parents. Do not leavethe infant unattended. Have bulb syringe available incase of need to suction oropharynx. If regular equip-ment for suctioning is required, validate by checkinglabel that all safety checks have been completed onequipment. Be aware of potential for young children toanswer to any name. Validate identification for proce-dures in all young children.

Keep siderails of crib up, and monitor safety of all attach-ments for crib or infant’s bassinet.

Check temperature of water before bathing and formulaor food before feeding. Do not microwave formula.

Maintain contact at all times during bathing. Infantsunable to sit must be held constantly. Older childrenshould be monitored as well, with special attentiongiven to mental or physical needs for a handicappedchild.

Place the infant on back with pacifier, for sleeping.Recommendations include infant to sleep in sameroom as caregivers. Special instructions may berequired with preterm infants and/or those with specialconditions, for example, gastroesophageal reflux.

Investigate any signs and symptoms that warrant potentialchild protective service referral.

Teach family basic safety measures:• Store plastic bags in cabinet out of child’s reach.• Do not cover mattress or pillows of the infant or child

with plastic.• Make certain crib design follows federal regulations

and that mattress has appropriate fit with crib frame.• Discourage co-sleeping in bed with the infant.• Avoid use of homemade pacifiers (use only those of

one-piece construction with loop handle).• Do not tie pacifier around the infant’s neck.• Untie bibs, bonnets, or other garments with snug fit

around neck of the infant before sleep.• Inspect toys for removable parts and check for safety

approval.

Will prevent medication or treatment errors.Anticipatory safety is an ongoing requisite for care of

children.

Infants and small children are prone to putting smallpieces in mouth, nose, or ears. Basic safety measures.

Helps prevent scalding or chilling of the infant.

Helps maintain airway. New updates regarding suddeninfant death syndrome (SIDS) now provide this man-date from the American Academy of Pediatrics. (Seesection on High Risk for SIDS.)

Provides assistance for the child and family in instancesof child abuse and is mandated by law.

Ensures environmental safety for the infant or child.Prevents possible suffocation.Adheres to new guidelines to prevent suffocation/reduces

SIDS risk.Same as above.

Danger of infant being rolled on.Danger of aspiration.

Danger of strangulation.Danger of strangulation.

Danger of aspiration.





••••••


Child Health


• Do not feed the infant foods that do not readily dis-solve, such as grapes, nuts, and popcorn.

• Keep doors of large appliances, especially refrigerators,closed at all times.

• Maintain fence and constant supervision around swim-ming pool.

• Exercise caution while cleaning, with attention to pailsof water and cleaning solutions.

• As the infant or child is able, encourage swimming les-sons with supervision and foster water safety.

• Use caution in exposure to sun for periods of longerthan 10 minutes. Use SPF sunblock for children, avoiddirect sunlight esp. from 11 A.M. to 4 P.M.

• Use appropriate seat belts and car seats according toweight and development.

• Keep matches and pointed objects, such as knives, in asafe place out of the child’s reach.

• Use lead-free paint on the child’s furniture andenvironment.

• Keep toxic substances locked in cabinet and out of thechild’s reach.

• Hang plants and avoid placement on floor and tables.• Discard used poisonous substances.• Do not store toxic substances in food or beverage

containers.• Administer medication as a drug, not as candy.• Use childproof medication containers.• Keep syrup of ipecac on hand in case of accidental

poisoning.• As applicable, use any special monitoring equipment as

recommended for the child.• Monitor mealtimes to prevent aspiration with giggling.

Danger of aspiration.

Danger of child being trapped inside refrigerator.

Prevents possible drowning.

Prevents possible drowning/aspiration.

Offers primary prevention to foster long-term watersafety.

Offers protective safety measure.

Women’s Health


Teach the patient and family the risk for injury to thefetus and patient when the pregnant woman smokes, isexposed to secondhand smoke, or engages in substanceabuse (e.g., alcohol and drugs [legal or illegal]).

Ask all patients about the existence of violence in theirhomes. Report child and elder abuse to proper authori-ties and any suspicion of family violence. Some statesrequire reporting of violence against women. (SeeChapters 9 and 11 for more detailed nursing actions.)

Provide atmosphere that allows the patient consideringabortion to relate her concerns and experiences and toobtain detailed information about the method of abor-tion that is being considered.

Provides initial safety information regarding the well-being of the fetus.

A legal requirement in some states.

Allows the patient to receive nonjudgmental informationabout the pros and cons of all choices available.


Injury, Risk For 65

••••••

Encourage questions and verbalization of the patient’slife expectations.

Provide information on options available to the patient. Thisis especially important in cases of domestic violence.

Assist the patient in identifying lifestyle adjustments thatthe decision could entail.

Involve significant others, if so desired by the patient, indiscussion and problem-solving activities regardinglifestyle adjustments.

In instances where the patient has performed a self-induced abortion, obtain detailed information regardingthe method used. Provide atmosphere that allows thepatient to relate her experience.

Ascertain whether abortifacients (castor oil, turpentine,lye, ammonia, etc.) or mechanical means (coat hanger,knitting needles, broken bottle, or knife) were used.

Regardless of the type of abortion, obtain a history fromthe patient that includes:

• Date of last menstrual period• Method of contraception, if any• Previous obstetric history• Known allergies to anesthetics, analgesics, antibiotics,

or other drugs• Current drug usage• Past medical history• Note the patient’s mental state (e.g., anxious, fright-

ened, or ambivalent).

Perform physical assessment with special notice of:• Amount and character of vaginal discharge• Temperature elevation• Pain• Bleeding: consistency, amount, and color

Teach the patient the importance of proper storage ofbirth control pills, spermicides, and medications.

Assist the patient in identifying drugs that are teratogenicto the fetus.

Assist the patient in becoming aware of environmentalhazards when pregnant, such as x-rays, people withinfections, cats (litter boxes), and hazards on the job(surgical gases, industrial hazards).

Some states require that information about local women’sshelters be provided when domestic violence is suspected.

In self-induced abortion, there is high probability of injuryand subsequent infection. This information provides thehealth team with basic data to begin assessing thedegree of injury.

Provides basic database to initiate planning of care.

To keep out of reach of children or others who should notuse these medications.

Provides information that allows the patient to plan forsafety during pregnancy.

Mental Health

In addition to the following interventions, refer to the applicable interventions provided in the Adult Health and HomeHealth sections of this diagnosis.


Orient the client to person, place, and time on each inter-action.

Provide appropriate assistance to the client as he or shemoves about the environment.

Disorientation can increase the client’s risk for injury ifthe environment is perceived as dangerous.

Prevents falls and possible injury.





••••••


Mental Health


Monitor level of consciousness every 15 minutes whenthe client is acutely disoriented following special treat-ments or when consciousness is affected by drugs oralcohol. If level of consciousness is impaired, place theclient on side to prevent aspiration of vomitus, andwithhold solid food until level of consciousnessimproves. Place the client in bed with siderails, andkeep siderails raised.

Do not allow the client to smoke without supervisionwhen disoriented or when consciousness is clouded.

Provide supervision for clients using new tools that couldprecipitate injury in special activities such as occupa-tional therapy.

Teach the client and members of support system:• Risks associated with excessive use of drugs and

alcohol.• Appropriate methods for compensating for

sensory–perceptual deficits (e.g., use of pictures orcolors to distinguish environmental cues when abilityto read is lost).

Remove all environmental hazards (e.g., personal groom-ing items that could produce a hazard, cleaning agents,foods that produce a hazard when taken with certainmedicines, plastic bags, clothes hangers, belt and ties,or shoestrings). Remove unnecessary pillows and blan-kets from the bed.

Maintain close supervision of the client. (If the client issuicidal, refer to nursing actions for Risk for Violence,Chapter 9, for specific interventions.)

Check the client’s mouth carefully after oral medicinesare given for any amounts that might be held in themouth to be used at a later date.

If the client is at risk for holding pills in the mouth to beused later, collaborate with physician to have doseschanged to liquids or injections.

Keep lavage setup and airway and oxygen equipment onstandby.

Talk with the client and members of support system aboutsituations that increase the risk for poisoning, anddevelop a list of these situations.

Label all medicines and poisonous substances appro-priately.

If client is in physical restraints:• Ensure that all least restrictive measures have been

attempted before restraints were initiated and ordersfor restraint meet JCAHO and institutional policy.

• Provide one-to-one monitoring at all times

Patient safety is of primary importance. Provides infor-mation about the client’s current status so interventionscan be adapted appropriately. Prevents aspiration byfacilitating drainage of fluids away from airway andprevents falls and possible injury.

Prevents the client from acting impulsively to injure selfwith items easily found in environment. This allowsstaff time to offer alternative coping strategies whenclients are experiencing difficulty with coping.

Prevents the client from acting impulsively.

Basic safety precaution.

Safety of client, other clients, and staff are of primaryimportance.87,104


Injury, Risk For 67

••••••

Gerontic Health

In addition to the following interventions, refer to the applicable interventions provided in the Adult Health and HomeHealth sections of this diagnosis.


Refer the independent elder to home health for homesafety assessment at least 3 days prior to dischargefrom hospital.

Minimize the use of or refrain from the use of physicaland chemical restraints.

Utilize restraint alternatives:• Environmental changes• Bed safety• Seating and position support• Toileting and continence programs• Increased supervision and staffing for high-risk clients• Alarms

Conduct a fall evaluation including an assessment of his-tory of falls, medications, vision, gait and balance,lower limb joints, and neurologic and cardiovascularfunction.

Utilize the “Get Up and Go” test to determine risk forfalls.112

I. Technique: Direct patient to do the followingA. Rise from sitting position.B. Walk 10 feet.C. Turn around.D. Return to chair and sit down.

II. InterpretationA. Patient takes �20 seconds to complete test.

1. Adequate for independent transfers and mobility.B. Patient requires �30 seconds to complete test.

1. Suggests higher dependence and risk of falls.Ensure that any sensory adaptations are made prior to

activities. (Client has clean glasses and/or functionalhearing aid available, as needed, adequate lighting tosafely move about, and clear pathway for ambulation.)

Initiate fall precautions, as indicated, on admission tocare facility, or on an as-needed basis.

Provides timely home care planning, and allows imple-mentation of safety measures before patient is dis-charged.

Use of chemical and physical restraints in elders is asso-ciated with risk of injury.

These alternatives can prevent falls without using poten-tially dangerous restraints.

Assists in determining modifiable risk factors for falls.

Assists in objectifying the client’s risk for falls.

The client may experience increased risks for injury ifsensory losses are not addressed.111,112

Use of fall prevention strategies reduces the risk for fallsin older adults and potential loss of function associatedwith falls and injuries.112,114

• Monitor client’s vital signs every 15 minutes• Offer food, water and toileting every 15 minutes• Inform client of conditions for restraint release• Release restraints, one limb at a time, on a scheduled

basis and assess circulation and sensation in affectedbody part. Note schedule here.

• Release client from restraint when client’s behavior isunder control and no longer poses a risk to themselvesor others.





••••••


Gerontic Health


Teach at-risk older adults fall prevention strategies:• Clients using mobility aids• Clients on medications that increase the potential for

vertigo, weakness, or orthostatic changes• Clients with motor or sensory deficits

Instruct the patient on safe administration of medication.Monitor for knowledge of drug dosage, reason formedication, expected effect, and possible side effects.Reinforce teaching on a daily basis.

If the patient suffers from dementia, teach the caregiverthe following safety adaptations116:

• Place in a locked closet articles, such as power tools,medications, or appliances, that the individual maymisuse and injure self or others.

• Ensure that water temperature is low enough to preventscalding.

• Remove knobs from stove if cooking is a fire hazard.• Install gates at the top of stairs to prevent falls.• Tape door latches or remove tumblers from locks to

prevent the patient from accidentally locking himself orherself in rooms.

• Place two locks on entry and exit doors if the individ-ual is prone to wandering.

• Ensure that furnishings do not have sharp edges or largeareas of glass that could cause injury during a fall.

Falls at home or in health-care settings are one of themain causes of morbidity and mortality in olderadults.111–115

Basic medication safety measures.

Older adults with the diagnosis of dementia often displaysigns of poor judgment. The listed teaching factorsdecrease the risk for injury in the home setting.

Home Health


Assist the client and family in obtaining a referral for gaittraining and training for appropriate use of assistivedevices. These can usually be obtained through a phys-ical therapy department.

Review medications with the client and family. Determineif medications may increase the client’s risk for falls;clients taking more than four medications, psychotropicmedications and antihypertensives. Collaborate withphysician or health-care practitioner to modify medica-tions as indicated.

Assist the client and family in locating and accessing anexercise program with balance training as one of thecomponents that is appropriate for the client’s healthstatus. These can usually be recommended by a physi-cal therapy department.

Assess the client for postural hypotension. Collaboratewith a physician as indicated for treatment of posturalhypotension.

Prevention activities reduce the risk of injury.

These medications may increase risk of falls.

Prevention activities reduce the risk of injury.

Postural hypotension is a modifiable risk factor for falls.



Injury, Risk For 69

••••••

Assist the client and family in adhering to the therapeuticregimen for cardiovascular disorders and cardiacarrhythmias.

Involve the client and family in planning, implementing,and promoting reduction in the risk for injury:

• Arrange family conferences to clarify risk factorsfor injury and preventive measures the family canimplement.

• Assist the family to define mutual goals for preventionof injury.

• Promote communication.• Assist family members with specific tasks as appropri-

ate to reduce the risk for injury.

Cardiovascular disorders and cardiac arrhythmias aremodifiable risk factors for falls.

Involvement of the client and family enhances motivationand increases the possibility of positive outcomes andthe long-term lifestyle changes required.

● N O T E : Restraining the client may increase, not decrease, the risk for injury.117

It is important to arrange the environment so that theclient can avoid injury (e.g., use bedside commode orraised toilet seat; remove unnecessary furniture;remove throw rugs, repair or remove loose or damagedflooring, pick up objects that may be blocking path-ways118–120; remove unsafe or improperly stored chemi-cals, weapons, cooking utensils, and appliances; useand store toxic substances safely; obtain certification infirst aid and CPR; properly store food; obtain knowl-edge of poisonous plants; learn to swim; remove firehazards from environment; design and practice anemergency plan for action if fire occurs; and properlyuse machines powered by petroleum products).

• Teach the client and family injury prevention activitiesas appropriate:

• Avoid the use of restraints for all clients, particularlyconfused clients.

• Proper lifting techniques• Assist family in securing patient lift equipment for

immobilized clients to prevent family/caregiver injury.• Removal of hazardous environmental conditions, such

as improper storage of hazardous substances, improperuse of electrical appliances, smoking in bed or nearsupplemental oxygen, open heaters and flames, andcongested walkways

• Proper ventilation when using toxic substances• First aid for poisoning• Proper labeling, storage, and disposal of toxic materials

such as household cleaning products, lawn and gardenchemicals, and medications

• Proper food preparation and storage• Proper skin, lung, and eye protection when using toxic

substances• Toxic substances out of reach of infants and young

children• Recognition of toxic plants and removal from environ-

ment as indicated• Plan of action if accidental poisoning occurs

Prevention activities reduce the risk of injury. Many peo-ple either do not know these prevention strategies orneed to have them reinforced.

Restraints have not been demonstrated to prevent falls andmay increase risk for other types of injuries. (NationalGuideline Clearinghouse, http://www.guideline.gov.)



LATEX ALLERGY RESPONSE,RISK FOR AND ACTUAL

DEFINITION44

At risk for or demonstrates an allergic reaction to naturallatex rubber products.


A. Risk for Latex Allergy Response1. Multiple surgical procedures, especially from infancy

(e.g., spina bifida)2. Allergies to bananas, avocados, tropical fruits, kiwi,

or chestnuts3. Professions with daily exposure to latex (e.g., medi-

cine, nursing, or dentistry)4. Conditions needing continuous or intermittent

catheterization5. History of reaction to latex (e.g., balloons, condoms,

or gloves)6. Allergies to poinsettia plants7. History of allergies and asthma

B. Latex Allergy Response1. Type I reactions: Immediate2. Type IV reactions

a. Eczemab. Irritationc. Reaction to additives causes discomfort (e.g., thiu-

rams, carbamates)d. Rednesse. Delayed onset (hours)

3. Irritant reactionsa. Erythemab. Chapped or cracked skinc. Blisters

RELATED FACTORS44

No immune mechanism response.


1. Any immune suppressed condition2. History of multiple surgeries3. History of multiple allergies4. Asthma5. Urinary bladder dysfunctions


••••••


Home Health


Assist the client and family in lifestyle adjustments thatmay be required.

Refer to appropriate assistive community resources asindicated

Participate in early-return-to-work programs.121

Participate in local, state, and national immunizationinitiatives.122

For long-term change, lifestyle adjustments are oftenrequired. Many people require assistance with thesechanges.

Use of existing community services is an efficient use ofresources.

Such programs lead to better client outcomes.

Community participation in immunization initiativesimproves the rate of appropriate immunization andreduces the risk of outbreak of the diseases for whichvaccines are available.


Impaired Tissue IntegrityIn this instance, the client has actual tissue damagesecondary to mechanical injury, radiation, etc. Therewill be actual breaks in the tissue, not just erythemaor blisters.

Ineffective ProtectionThe patient with this diagnosis will have a decrease inthe ability to guard against internal or external threats.The related factors for this diagnosis are much broaderthan just one response to an identified allergen.

EXPECTED OUTCOME

Will describe at least [number] different measures to use toavoid Latex Allergy Response by [date].

TARGET DATES

With appropriate therapy, the signs and symptoms of LatexAllergy Response begin to abate within 48 to 72 hours; thus,an appropriate target date would be 2 to 3 days.


Latex Allergy Response, Risk for and Actual 71

••••••


Adult Health


Type I reaction:• Remove all latex products possible.• Stop treatment or procedure.• Support airway; administer 100 percent oxygen.• Start IV with volume expander.• Give the following drugs according to physician order:

• epinephrine• antihistamines• steroids

Clearly identify patients who have a latex allergy withsigns both at the bedside and on the chart and arm-bands.115–118

Isolate the patient if possible.

Encourage patients to purchase and wear a MedicAlert®

ID bracelet or necklace.123–126

Report latex allergy to the Food and DrugAdministration’s MedWatch program at (800) FDA-1088.123–126

Identify routinely used supplies that contain latex.123–126

Identify latex-safe alternatives for these frequently usedsupplies.123–126

Remove all latex-containing materials from the patient’sbedside.123–126

Replace latex-containing items with latex-safealternatives.115–118

Notify other departments as needed:

• Pharmacy

• Dietary (avoid bananas, avocados, and chestnuts)

• Physical Therapy and Occupational Therapy, ifappropriate

• Surgical Services• Respiratory Therapy• Radiology• Laboratory• Material Management• Environmental Services

Pad blood pressure cuff before taking blood pressure.Use nonpowdered latex gloves that have low protein con-

tent or vinyl gloves or nitrile gloves made of syntheticmaterial with latex-like characteristics. When you mustwear powdered latex gloves, never snap them on or off.

Use latex-free equipment and keep carts filled with theseproducts. It is particularly critical that latex-free life-support equipment is included in the carts.

Anaphylactic emergency.

Alert all health-care workers that latex precautions mustbe taken in case emergency services are ever needed.

Establishes accurate data on latex allergies.

Ensures a latex-safe environment.

Ensures adequate communication among departmentsand coordination of care to provide a latex-safeenvironment.

So that medications can be prepared in a latex-freeenvironment using nonlatex products.

So that latex gloves worn by the personnel preparing foodcan be substituted with a vinyl alternative.

Ensure that all therapy equipment is latex-free.

Aerosolized latex protein from the latex glove powder isone of the biggest contributing factors in triggering alatex reaction.

If a patient has an emergency event, it should not be com-pounded by having equipment that could worsen theevent.




••••••


Adult Health


Do not inject through intravenous tubing injection ports.Use stopcock as needed. Use only latex-safe syringes.

Do not aspirate medications through rubber stopper ofmultidose vials; remove stopper and aspirate contentsdirectly.

Check the manufacturer’s product label for latex content.Prohibit latex balloons in the patient’s room. Mylar bal-

loons are a latex-safe alternative.Include allergy information in all reports given to other

departments.Document the use of latex-free products during care.

Monitor for any adverse reactions.If a reaction does occur, document the presence of the

reaction, and the steps that were taken to treat it.Document the patient’s response to treatment.

Notify the physician immediately if the patient does havean allergic reaction to latex.

Assess the patient’s and family’s need for educationrelated to latex allergy and provide that which isneeded.

Common sources of latex at home and at work:• Art supplies• Bandages• Balloons• Balls• Carpet backing• Cleaning gloves• Condoms or diaphragms• Diapers• Douche bulbs• Elastic in clothing• Elastic in hair accessories• Erasers• Eye drop bulbs• Feeding nipples• Food handled with latex gloves• Handles (rubber) on tools, racquets, and bicycles• Hot water bottles• Infant toothbrush massager• Koosh balls• Pacifiers• Paints• Rubber clothing (e.g., raincoats)• Rubber toys• Shoes• Tires• Wheelchair cushions

Document the patient’s and family’s response to theteaching.

Ensures a latex-safe environment.

Documentation is vitally important in patient care.


Latex Allergy Response, Risk for and Actual 73

••••••

Child Health


Risk forAssess for signs and symptoms suggestive of latex

allergy, including sneezing, coughing, rash, hives, orwheezing in the presence of balloons, Koosh balls,catheters, or other rubber items.127,128

Determine the history for the infant or child to note anyallergic reactions, including triggering event or sub-stance, actual symptoms, treatment required, and exac-erbations.

Determine whether the infant or child has undergoneallergy testing, has received results, and has undergonea treatment regimen.

Ask whether the infant or child has been diagnosedwith a condition that requires contact with catheters orother hospital products, such as gloves or monitoringequipment.

Ask whether the infant or child has ever experienced anallergic reaction during surgery.

List any known foods, drugs, or allergenic substances forthe infant or child.

Provide appropriate identification alerts for records andidentification bands as the child is cared for to signifyallergenic status to latex.127,128

Ask the parents how they would identify an allergic reac-tion in their child.

Find out whether the parents are aware of emergencyequipment and treatment that may be required in theevent of latex allergenic response.

As dismissal planning is done, ensure the availability ofemergency medical services (EMS), how to summonEMS, appropriate use of equipment, and how to main-tain a plan in event of need.

Carry out health interview with focus on components todetermine positive history or likelihood of latexallergy* medical diagnosis of spina bifida(myelomeningocele is a high risk).

Note most recent allergy testing, known allergies, currenttreatment, and plan for how best to prepare for electivesurgery or treatments within hospital or clinic.

Note history of allergenic responses to latex with atten-tion to ongoing risk indices such as implants or needfor special medical equipment such as catheters.127,128

Identify appropriate treatment for known latex allergies toinclude need for special airway and oxygen deliveryequipment, medications such as epinephrine, and spe-cialists who will be available to assist in event of acuteallergenic response.

Identification of at-risk populations aids in diagnosis oflatex allergy.

Knowledge of individual’s status assists in identifica-tion of at-risk or actual latex allergy and treatmentas reference in event of recurrence and for preventivesuggestions.

Documentation of known status is essential to considerpossible change from potential to actual allergenicstatus.

Identification of risk factors assists in prevention of latexallergy development for all populations.

Surgery imposes a risk for latex allergy development.

Evidence of absence is essential; presence of history willbe needed for risk reduction for exacerbation.

Proper identification serves to lessen the likelihood ofrepeated exposure and precipitation of latex allergicresponse.

Individualized assessment provides validation of knowl-edge and values the importance of each possible mani-festation of allergic response.

Assessment for treatment is vital to management of pos-sible allergic response to expedite intervention andminimize delay in event of emergency.

Anticipatory planning assists in empowerment of parentsto act in event of emergency, thereby ensuring bestchance for treatment without delay.

Determination of a latex allergic client alerts all to needfor precautionary measures.

Exposure to latex early in life with repeated exposures infirst years of life increases likelihood for latex allergy.

Documentation of status provides appropriate basis forprecautionary treatment of client.

Identification of risk indices alerts caregivers to likeli-hood of precautions to be implemented.

Anticipatory planning will best provide for possibleemergency without delay.




••••••


Child Health


Provide identification bracelet and appropriate designa-tion of latex allergy status for the infant or child permedical record and ensure its appropriate sharing withall who will provide care for client (including daycareproviders, teachers, or sitters).

Assess parental knowledge of current plan of care with afocus on potential allergenic triggers prior to dismissaland for ongoing care.

Assess for stressors related to the infant or child’s latexallergy status.

Anticipatory planning and valuing of risk for acute aller-genic response is best met with dissemination to signif-icant caregivers for provision of greater freedom fromrisk and prevention of latex allergic recurrence.

Anticipatory planning for the individual places value onthe preventive component.

Valuing feelings and perceptions of the client and familyfosters open communication and provides cues forrelated nursing needs.

Women’s Health

● N O T E : The nursing actions for a woman with the nursing diagnosis of latex allergyare the same as those for Adult Health. Be aware that infants born to mothers with latexallergies could themselves be allergic to latex, and all the precautions taken with themother should be followed with infants. This includes padding the crib well to keep theinfant away from the crib mattress covers, which usually have latex in them.

Research studies have shown that glove powder binds to latex proteins and istherefore a major hazard and contributor to the amount of latex found in the air in oper-ating rooms and patient rooms where gloves are routinely used. It has been shown thatpatients and health-care workers are exposed on a continuous basis when working inrooms in which there is a high usage of gloves with powder, as bound proteins areaerosolized when gloves are dispensed, put on, used, and/or removed from the hands.Health-care personnel and patients in labor and delivery are particularly vulnerable andat risk for latex allergy because of the high use of gloves during vaginal examinations ofthe patient in labor and during cesarean sections. Likewise, the health-care workerneeds to be aware of the presence of latex in nipples on infant bottles.


Replace all examination gloves and sterile gloves inobstetric units with vinyl or low-allergen, powder-freelatex gloves.

When using vinyl gloves during pelvic examinations, insurgery, or when dealing in any situation requiringstandard precautions, always double glove.

Carefully interview the pregnant client and screen for riskfor latex allergy. Question about past pregnancy out-comes, particularly if they have had any infants withneural tube defects (e.g., spina bifida).

A major reason for the increase in sensitization rates inhealth-care workers and patients is the use of productscontaining high levels of extractable proteins, such aspowdered, high-allergen gloves.124,125

Because of the high failure rate of vinyl gloves, it is rec-ommended to use low-allergen, powder-free latexgloves during high-risk situations involving standardprecautions; however, if there is a need for the use ofno latex products (such as with the latex-sensitivepatient or health-care worker), then the health-careworker using vinyl gloves should double glove for hisor her own protection.

Because of the frequent use of gloves, catheters, etc. inthe care of these babies, both the baby and the care-taker may have developed a sensitivity to latex.(Approximately 72 percent of patients with spina bifidaare allergic to latex.)127,128


Management of Therapeutic Regimen, Effective 75

••••••

Pregnant mothers who have been involved with the careof a previous child that could have involved exposureto latex products, and/or their newborn infant, shouldbe treated with latex avoidance regardless of theirallergy status.

Carefully monitor the mother and her newborn forsymptoms of an allergic reaction, including a systemicreaction.

Teach the mother and her family the essentials of latexprecautions:

• Review of routes of exposure• Use of infant and toddler supplies and toys

This mother and her newborn are at risk for a potentialreaction to latex.126,127

Mental Health

Nursing interventions and rationales for this diagnosis are the same as those for Adult Health.

Gerontic Health

Use information provided in Adult Health section for this diagnosis. Currently there is no evidence available to suggestspecific interventions for this diagnosis based on age of the client.

Home Health


Inquire about sensitivity to latex or other related factorsat onset of care.

Assist the client in acquiring a MedicAlert bracelet whenlatex allergy is present.

Assist the client in securing latex-free supplies forhome use.

Educate the client, family members, and potentialcaregivers about latex-containing devices andequipment, as well as the signs of acute allergicreactions.

Educate the client, family members, and potentialcaregivers how to access emergency medical careshould an accidental exposure precipitate an acutereaction.

Assist the client and family in obtaining an epineprhrinepen for use in case of anaphylactic reaction to latex.

Allows early identification of potential for allergicreactions.

Prevents further exposure to latex products.

Prevents further exposure to latex products.

Encourages family participation in client care andreduces potential for accidental exposure.

Prevents further morbidity.


MANAGEMENT OF THERAPEUTICREGIMEN, EFFECTIVE

DEFINITION44

A pattern of regulating and integrating into daily living aprogram for treatment of illness and its sequelae that is sat-isfactory for meeting specific health goals.


1. Appropriate choices of daily activities for meeting thegoals of a treatment or prevention program

2. Illness symptoms are within a normal range ofexpectation

3. Verbalized desire to manage the treatment of illness andprevention of sequelae




••••••


Adult Health


Allow time for the patient to discuss his or her feelingsabout the therapeutic regimen.

Support the patient in choices made to effectively managetherapeutic regimen.

Review availability and use of resources and supportgroups.

Answer questions about disease process and therapeuticregimen. Provide teaching for any new components oftherapeutic regimen.

Assist the patient to solve problems as they arise.

Allow and monitor self-care while in the hospital.

Have the patient return/demonstrate activities associatedwith therapeutic regimen (e.g., dressing changes; glu-cose testing; blood pressure checks; counting calories,fat grams, carbohydrates, and sodium intake; self-administering medications). Supervise performance,critique, and reteach as necessary.

Review self-reported plan of activities with the patient,and continue to encourage its use and the sharing ofthe plan with the patient’s employer and physician.

Review accomplishment of goals of therapeutic regimen,and praise the patient for even small accomplishments.

Allow at least 30 minutes a day for the patient to verbal-ize possible conflicts with therapeutic regimen. Role-play possible scenarios.

Have the patient make follow-up appointments withappropriate resources or health-care providers prior todischarge.

Continue to coordinate care with other health-careproviders or community resources.

Encourages the patient’s sense of control and strengthenssupport systems.

Encourages the patient’s sense of self-control.

Promotes independence.

Provides feedback for skills; reaffirms motivation.

Provides visual record of plan that is integrated intopatient’s lifestyle.

Improves motivation and gives the patient a sense ofachievement.

Provides an opportunity for patient to verbalize and actout alternate coping strategies in a nonthreatening envi-ronment.

Facilitates continuity and consistency of plan.

Promotes patient advocacy.

4. Verbalized intent to reduce risk factors for progressionof illness and sequelae

RELATED FACTORS44

To be developed.


Any condition requiring long-term management; for exam-ple, cardiovascular diseases and diabetes mellitus.

EXPECTED OUTCOME

Subsequent assessments document continued progresstoward health by [date].

TARGET DATES

Effective management of a therapeutic regimen requires alifelong commitment by the client. Therefore, target dateswill vary from weeks to years. It would be appropriate to setthe first target date for 1 month after the patient’s discharge.


There are currently no other diagnoses this diagnosiscould be compared with, or that are close to, the con-cept of this diagnosis. This diagnosis could be classi-

fied as a wellness diagnosis; that is, the patient withthis diagnosis is progressing toward wellness andappropriate health maintenance.



••••••

Child Health


Utilize appropriate age and developmental commu-nication.

Determine the client’s and primary caregiver’s perceptionof condition.

Assist the family to determine when and where follow-upcare will be utilized.49,50

Offer verbal and emotional reinforcement for appropriateattendance to mutually agreed-to criteria. State criteriahere (e.g., maintain immunizations).

Acknowledge need for the caregiver to be relieved (atregular intervals) of total responsibilities of dependentinfant or child. Encourage the caregiver to express feel-ings regarding responsibility. Delineate communityresources that can augment care.49,50

Identify subsequent factors that are likely to resurfaceover time (e.g., developmental concerns).

Assists in developing a trusting relationship with theclient and primary caregiver.

Provides a starting point for discussing and teaching ther-apeutic regimen.

Promotes long-term management.

Provides positive reinforcement.

Assists in preventing caregiver role strain. Promoteseffective management.

Anticipatory guidance is central to nursing.

Women’s Health


Utilize Prenatal Risk Indicator Tools to identify womenwho are high risk for pregnancy and birth. Assess andcounsel those mothers identified as high risk. Assist thepatient to plan changes necessary in her lifestyle tomaintain pregnancy and health of mother and fetusuntil birth.29

Provide the new mother with information about varioussupport groups and health-care programs when earlypostpartum discharge occurs. Provide teaching andsupport on an ongoing basis from time of conceptionuntil end of postpartum period for the new mother, herfamily, and her baby. Provide new parents with writtenhandouts, help-line telephone numbers, follow-upappointments with advanced practice nurse, pediatri-cian, and obstetrician following postpartum discharge.

Provides the patient with the information needed to makeinformed choices and necessary lifestyle changes inorder to maximize health for herself and her fetus.

Provides the patient with the information needed to makeinformed choices and necessary lifestyle changes inorder to maximize health for herself and her fetus.

Mental Health


Sit with the client [number] minutes [number] times aday to discuss:

• His or her understanding of the current situation• Strategies that assist the client in this management• Support systems• Stressors

[Note important data from these discussions here.]

Discuss with the client signs and symptoms that wouldindicate that assistance is needed with management.

Promotes the development of a trusting relationship bycommunicating respect for the client.69 Providesassessment data that will assist in the development of aplan to support client’s current behaviors.

Support systems promote healthy behaviors.88

Promotes the client’s sense of control.97




••••••


Mental Health


Develop with the client a plan for obtaining the necessaryassistance when needed.

Provide positive social reinforcement and other behavioralrewards for demonstration of adaptive management.(Those things that the client finds rewarding should belisted here with a schedule for use. The kinds of behav-iors that are to be rewarded should also be listed.)

Discuss with the client the impact of stress on physio-logic and psychological well-being. Develop with theclient a plan for learning relaxation techniques, andhave client practice technique for 30 minutes 2 times aday at [times] while hospitalized. Remain with theclient during practice session to provide verbal cuesand encouragement as necessary. These techniques caninclude:

• Meditation• Progressive deep muscle relaxation• Visualization techniques that require the client to visu-

alize scenes that enhance the relaxation response• Biofeedback• Prayer• Autogenic training

Develop with the client a plan for integrating relaxationtechniques into daily schedule at home.

Develop with the client a plan to include play into dailyactivities. Note the plan and specific activities here.

Establish a time to meet with the client and those mem-bers of his or her support system identified as mostimportant. Note time here. Utilize this time to discuss:

• Support system’s understanding of the client’s situation• Support system’s perceptions of their involvement with

the management of the illness• Support system’s perceptions of their needs at this time

Develop with the members of the support system a planto meet the perceived needs. [Note this plan here.]

Identify, with the client, community support groups thatcan be utilized when he or she returns home. Notethose groups identified here with a plan for contactingthem before the client leaves the hospital.

Positive reinforcement encourages adaptive behavior andenhances self-esteem.87

Anxiety decreases coping abilities and physiologic well-being. Repeated rehearsal of a behavior internalizesand personalizes it.87

Having a concrete plan increases the probability that thebehavior will be implemented in the new environment.

Play provides a sense of joy and rejuvenates inner vital-ity, enhancing coping abilities.69

Interactions between members of the support systemand the individual can impact individual health andcoping.87,88 Provides an opportunity to assess sup-port system’s perspective to assist in developinginterventions and further their acceptance of theintervention.69,88

Increases support system’s sense of control while enhanc-ing self-esteem. Provides opportunities for increasingsupport system coping by recognizing that the illnesshas an impact on this system.69,88

Groups can provide hope, information, and role modelsfor coping and support.88

Gerontic Health


Monitor at each subsequent contact for continued abilityto effectively manage regimen.

Physiologic aging or exacerbation of chronic illness may,over time, diminish continued ability to implementregimen.



••••••

Home Health


Assess the client/family understanding of the current dis-ease process and therapeutic regimen.

Assess client/family strategies for managing the therapeu-tic regimen and assist in the provision of communityresources that might support continued use of thesestrategies.

Discuss the therapeutic regimen and strategies for manag-ing the regimen with client and family regularly (asdetermined to be appropriate by the nurse) to ensurecontinued accurate understanding and effective use ofstrategies.

Provide education as the client’s condition or regimenchanges.

Involve the client, family, and community in planning,implementing, and promoting the treatment planthrough129,135,137:

• Assisting with family conferences.• Coordinating mutual goal setting.• Promoting increased communication.

Identifies knowledge deficits or misunderstanding to pre-vent problems.

Supports the continued use of effective strategies.

Clients/families may not be able to maintain sustainedmanagement, this will allow for early identification ofproblems.

Ensures that the client/family can maintain their currenttherapeutic management of the regimen.

Involvement increases motivation and improves the prob-ability of success.

Refer to community resources as indicated.

Establish communication link with primary caregiver andfamily.

Advise family members of availability of managed careresources in the community where older client resides.

Provide follow-up support via home visits and telephonecontacts.

Assist caregivers in establishing and meeting their needs.

Review with the client and family the therapeuticregimen.

Provide multisensory teaching materials (tapes, websites,literature) on therapeutic regimen to assist client andcaregiver in adhering to regimen.

Incorporate a variety of local, regional, or state socialservices to ensure that needed information about theregimen is available to older patients.

Identify older community leaders, via age-related groupsor associations, who can identify strengths or weak-nesses of the community (such as senior citizen centermembers, church groups, and support groups focusedon problems common to older adults).

The older patient may have concerns related to availabil-ity of support systems, costs of medication, and avail-ability of transportation. Use of already availablecommunity resources provides a long-term, cost-effective support system.

Family members may not be geographically available.

Provides care options for family to consider.

Presents opportunities for continued problem solving andincreasing trust.

Enables continuation of care while decreasing the poten-tial for burnout.

Helps determine possible areas of difficulty for client orcaregiver.

Provides quick access to information for the caregiver orclient.

Information flow may be impeded because of temporaryrelocation or social isolation.

Peer or cohort influences may assist in identifying andpromoting problem solving.




MANAGEMENT OF THERAPEUTICREGIMEN (INDIVIDUAL, FAMILY,COMMUNITY), INEFFECTIVE

● N O T E : This diagnosis was proposed at the TenthNANDA Conference with the result that a proposal todelete Noncompliance was expected to be presented at thenext conference. However, this has not occurred to date. Asdiscussed in the conceptual section of this chapter, and inadditional information later in this section, there are manypeople who object to the diagnosis of Noncompliance. Forthis reason, we will not provide nursing actions forNoncompliance but will provide the definition, definingcharacteristics, and related factors for this diagnosis untilit is officially deleted. In 1994, the categories of Familyand Community were added.

DEFINITIONS44

Ineffective Management of Therapeutic Regimen (Indi-vidual) A pattern of regulating and integrating into dailyliving a program for treatment of illness and the sequelaeof illness that is unsatisfactory for meeting specific healthgoals.

Noncompliance (Specify) The extent to which aperson’s and/or caregiver’s behavior coincides or fails tocoincide with a health-promoting or therapeutic plan agreedupon by the person (and/or family and/or community) andhealth-care professional. In the presence of an agreed upon,health-promoting or therapeutic plan, person’s or caregiver’sbehavior is fully or partially nonadherent and may lead toclinically effective, partially effective, or ineffective out-comes.


••••••


Home Health


• Assigning family members specific tasks as appropriateto assist in maintaining the therapeutic regimen plan(e.g., support person for patient, transportation, or com-panionship in meeting mutual goals).

• Utilizing population surveillance to detect changes inillness patterns for the community.

• Support the client, family, or community in eliminatingbarriers to implementing the regimen by:

• Providing for privacy.• Referring to community services (e.g., church, home

health volunteer, transportation service, or financialassistance).

• Providing for interpreters and for community-basedlanguage classes for English speakers to learn otherlanguages as well as for non-English speakers to learnEnglish.

• Serving as social activist to encourage necessaryparticipants to complete their tasks. This mayinclude fund-raising, testifying before governingbodies, or coordinating efforts of several groupsand organizations.

Assign one health-care provider or social service worker,as much as possible, to provide continuity in careprovision.

Make timely telephone calls to clients to discuss care(e.g., 1 day after being seen in clinic for minor acuteinfection, or weekly or monthly on a routine schedulefor chronically ill person).140

Reteach the client and family appropriate therapeuticactivities as the need arises.

Many barriers are institutional and can be eliminated orreduced.

Continuity of care provides a means for effective problemsolving and early identification of problems.

Follow-up with clients reinforces positive behaviors andmay aid in early identification of problems. Follow-upalso implies support of health-care professionals.

Reinforcement of information and continued assistancemay be required to improve implementation of thetherapeutic regimen.137


Management of Therapeutic Regimen (Individual, Family, Community), Ineffective 81

••••••

Ineffective Management of Therapeutic Regimen(Family) A pattern of regulating and integrating into fam-ily processes a program for treatment of illness and thesequelae of illness that is unsatisfactory for meeting specifichealth goals.

Ineffective Management of Therapeutic Regimen(Community) A pattern of regulating and integrating intocommunity processes programs for treatment of illness andthe sequelae of illness that is unsatisfactory for meetinghealth-related goals.


A. Ineffective Management of Therapeutic Regimen(Individual)1. Choices of daily living ineffective for meeting the

goals of a treatment or prevention program2. Verbalized desire to manage the treatment of illness

and prevention of sequelae3. Verbalized that he or she did not take action to reduce

risk factors for progression of illness and sequelae4. Verbalized difficulty with regulation and/or integra-

tion of one or more prescribed regimens for treatmentof illness and its effects or prevention of complica-tions

5. Acceleration (expected or unexpected) of illnesssymptoms

6. Verbalized that he or she did not take action toinclude treatment regimens in daily routines

B. Noncompliance1. Behavior indicative of failure to adhere (by direct

observation or by statements of patient or significantothers)

2. Evidence of development of complications3. Evidence of exacerbation of symptoms4. Failure to keep appointments5. Failure to progress6. Objective tests (physiologic measures or detection of

markers)C. Ineffective Management of Therapeutic Regimen

(Family)1. Inappropriate family activities for meeting the goals

of a treatment or prevention program2. Acceleration (expected or unexpected) of illness

symptoms of a family member3. Lack of attention to illness and its sequelae4. Verbalized desire to manage the treatment of illness

and prevention of the sequelae5. Verbalized difficulty with regulation and/or integration

of one or more effects or prevention of complication6. Verbalized that family did not take action to reduce

risk factors for progression of illness and sequelaeD. Ineffective Management of Therapeutic Regimen

(Community)1. Illness symptoms above the norm expected for the

number and type of population

2. Unexpected acceleration of illness(es)3. Number of health-care resources is insufficient for the

incidence or prevalence of illness(es)4. Deficits in people and programs to be accountable for

illness care of aggregates5. Deficits in community activities for secondary and

tertiary prevention6. Deficits in advocates for aggregates7. Unavailable health-care resources for illness care


Deficient KnowledgeThis is the most appropriate diagnosis if the patientor family verbalizes less than adequate understandingof health management or recalls inaccurate healthinformation.

Ineffective Individual Coping or Compromisedor Disabled Family CopingThese diagnoses are suspected if there are major dif-ferences between the patient and family reports ofhealth status, health perception, and health-carebehavior. Verbalizations by the patient or familyregarding inability to cope also indicate this differentialnursing diagnosis.

Dysfunctional Family ProcessesThrough observing family interactions and communi-cation, the nurse may assess that Altered FamilyProcesses is a consideration. Poorly communicatedmessages, rigidity of family functions and roles, andfailure to accomplish expected family developmentaltasks are a few observations that alert the nurse tothis possible diagnosis.

Activity Intolerance or Self-Care DeficitThese diagnoses should be considered if the nurseobserves or validates reports of inability to completethe tasks required because of insufficient energy orbecause of inability to feed, bathe, toilet, dress, andgroom self.

Disturbed Thought ProcessesThe nursing diagnosis of Disturbed Thought Processesshould be considered if the patient exhibits impairedattention span; impaired ability to recall information;impaired perception, judgment, and decision making;or impaired conceptual and reasoning abilities.

Impaired Home MaintenanceThis diagnosis is demonstrated by the inability ofthe patient or family to provide a safe home livingenvironment.

RELATED FACTORS44

A. Ineffective Management of Therapeutic Regimen(Individual)1. Perceived barriers2. Social support deficits



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3. Powerlessness4. Perceived susceptibility5. Perceived benefits6. Mistrust of regimen and/or health-care personnel7. Knowledge deficits8. Family patterns of health care9. Excessive demands made on individual or family

10. Economic difficulties11. Decisional conflicts12. Complexity of therapeutic regimen13. Complexity of health-care system14. Perceived seriousness15. Inadequate number and types of cues to action

B. Noncompliance1. Health-care plan

a. Durationb. Significant othersc. Costd. Intensitye. Complexity

2. Individual factorsa. Personal and developmental abilitiesb. Health beliefsc. Cultural influencesd. Spiritual valuese. Individual’s value systemf. Knowledge and skill relevant to the regimen

behaviorg. Motivational forces

3. Health systema. Satisfaction with careb. Credibility of providerc. Access and convenience of cared. Financial flexibility of plane. Client–provider relationshipf. Provider reimbursement of teaching and follow-upg. Provider continuity and regular follow-uph. Individual health coverage

4. Networka. Involvement of members in health planb. Social value regarding planc. Perceived beliefs of significant others

C. Ineffective Management of Therapeutic Regimen(Family)1. Complexity of health-care system2. Complexity of therapeutic regimen3. Decisional conflict4. Economic difficulties5. Excessive demands made on individual or family6. Family conflict

D. Ineffective Management of Therapeutic Regimen(Community)1. Perceived barriers2. Social support deficit3. Powerlessness4. Perceived susceptibility

5. Perceived benefits6. Mistrust of regimen and/or health-care personnel7. Knowledge deficit8. Family patterns of health care9. Family conflict

10. Excessive demands made on individual or family11. Economic difficulties12. Decisional conflicts13. Complexity of health-care regimen14. Complexity of health-care system15. Perceived seriousness16. Inadequate number and types of cues to action


1. Any diagnosis new to the patient; that is, patient doesnot have education or experience in dealing with thisdisorder.

2. Any diagnosis of a chronic nature, for example, pain,migraine headaches, rheumatoid arthritis, or a terminaldiagnosis.

3. Any diagnosis that has required a change in health-careproviders, for example, referred from long-time familyphysician to cardiologist.

ADDITIONAL INFORMATION

Some nursing authors object to the term “Noncompli-ance.”135–137,140–142 Compliance can become the basis for apower-oriented relationship in which one is judged andlabeled compliant or noncompliant based on the hierarchicalposition of the professional in relation to the patient. Thediagnosis of Noncompliance is to be used for those patientswho wish to comply with the therapeutic recommendationsbut are prevented from doing so by the presence of certainfactors. The nurse can in such situations strive to lessen oreliminate the factors that preclude the willing patient fromcomplying with recommendations.

The principles of informed consent and autonomy143

are critical to the appropriate use of this diagnosis. A personmay freely choose not to follow a treatment plan. The nurs-ing diagnosis Noncompliance does not mean that a patient isnot willing to obey, but rather that a patient has attempted aprescribed plan and has found it difficult to follow throughwith it. The area of noncompliance must be specified. Apatient may follow many aspects of a treatment programvery well and find only a small part of the plan difficult tomanage. Such a patient is noncompliant only in the area ofdifficulty.

Several nursing authors have recognized the interde-pendent nature of illness and healing.138–143 This interde-pendence is especially pronounced in chronic illness. As apatient and his or her family adapts to a chronic condition,noncompliance with prescribed treatment regimens mayactually be constructive and therapeutic, not detrimental.140

The nurse who learns to listen to the patient and plan treat-



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ments in collaboration with the patient will benefit from thewisdom of people experiencing illness.130,134

EXPECTED OUTCOME

Will return-demonstrate appropriate technique or proce-dures [list] for self-care by [date].

TARGET DATES

The specific target dates for these objectives will be directlyrelated to the barriers identified, the patient’s enter-ing level of knowledge, and the comfort the patient feels inexpressing satisfaction or dissatisfaction. The target datecould range from 1 to 5 days following the date of admission.


Adult Health


Help the patient and/or family identify potential areas ofconflict (e.g., values, religious beliefs, cultural mores,or cost).

Make a list of these potential areas of conflict and helpthe patient and/or family problem solve each areaone at a time. Note the list here with plan for problemsolving.

From time of admission, utilize each patient encounter toprovide instructions for self-care. Teach the patient andsignificant others knowledge and skills needed toimplement the therapeutic regimen (e.g., measuringblood pressure, counting calories, administering med-ications, or weighing self). [Note teaching topics andschedule here.]

Assist the patient and/or family in identifying factors thatactually or potentially may impede the desired thera-peutic regimen plan:

• Sense of control• Language barriers (provide translators, assign nursing

personnel to care for patient who speak the patient’slanguage)

• Cultural concerns (cultural mores, religious beliefs,etc.; design a plan that will allow incorporation of thetherapeutic regimen within the cultural norms of thepatient)

• Financial constraints• Knowledge deficits• Time constraints• Level of knowledge and skill related to treatment plan• Resources available to meet treatment plan objectives• Complexity of treatment plan• Current response to treatment plan• Use of nonprescribed interventions• Entry to health-care system

Allow opportunities for the patient and family to expressfeelings and to verbalize fears related to therapeuticregimen (e.g., body image, cost, side effects, pain, ordependency) by devoting at least 30 minutes per day tothis activity. [List times here.]

Assesses motivation and decreases risk of ineffectivemanagement of therapeutic regimen.

Provides time to incorporate changes into lifestyle andto practice as necessary before day of discharge fromhospital.

Assesses motivation and decreases risk of diagnosisdevelopment.

Increases the patient’s sense of control. Facilitates conti-nuity and consistency of plan.




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Adult Health


Design a chart to assist the patient to visually see theeffectiveness of therapeutic regimen (e.g., weight losschart, days without smoking, blood pressure measure-ments). Begin the chart in hospital within 1 day ofadmission. Follow up 1 week after discharge.

Assist in the development of a schedule that will allowthe patient to keep appointments and not miss work.Forward plan to employer and physician.

Assist the patient in developing time-management skillsto incorporate time for relaxation and exercise. Havepatient develop a typical 1 week schedule, then workwith patient to adapt schedule as needed.

Contract, in writing, with the patient and/or significantothers for specifics regarding regimen. Have patientand family establish mutual goal setting sessions.Assign specific family members specific tasks. Followup 1 week after discharge; recheck 6 weeks followingdischarge.

Design techniques that encourage the patient’s or family’simplementation of the regimen, such as setting single,easy-to-accomplish, short-term goals first and progress-ing to long-term goals as the short-term goals are met.If the idea of stopping smoking is too overwhelming,help the patient design a personal adaptive program. Forexample, change to a lower tar/nicotine cigarette, imple-ment timed smoking (e.g., only one cigarette every 30or 60 minutes), stabilize, then make further reductions.

Teach the patient and significant others assertive tech-niques that can be used to deal with dissatisfactionwith caregivers.

Assist in correction of sensory, motor, and other deficitsto the extent possible through referrals to appropriateconsultants (e.g., occupational therapist, physical thera-pist, ophthalmologist, audiologist).

Have the patient and/or family design a home care plan.Assist the patient to modify the plan as necessary.Forward the plan to home health service, social serv-ice, physician, etc.

Relate any information regarding dissatisfaction to theappropriate caregiver (e.g., to physician, problems withthe time spent in waiting room, cultural needs, privacyneeds, costs, need for generic prescriptions).

Make follow-up appointments prior to the patient’s leav-ing the hospital. Do it from the patient’s room, and putappropriate information regarding appointment onbrightly colored card (i.e., name, address, time, date,and telephone number).

Visualization of actual progress promotes implementationof prescribed regimen.

Demonstrates importance of schedule to patient,employer, and physician. Coordinated effort encour-ages adherence to regimen.

Individualizes schedule and highlights need for relaxationand exercise.

Demonstrates, in writing, the importance of the plan, andby listing definitive follow-up times, enhances theprobability of regimen implementation. Involvementincreases motivation and improves the probability ofsuccess.

Prevents multiple changes from overwhelming patient,thus avoiding one major contributor to ineffective man-agement of therapeutic regimen.

Long waiting periods in offices, unanswered questions,being rushed, etc. increase the likelihood of abandon-ing the regimen. Assertiveness helps the patient andfamily overcome the feelings of powerlessness andincreases the sense of control.

Demonstrates exactly how to make appointments forpatient.



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Child Health

● N O T E : Because of the dependency of the infant or child, ineffective management willalways include both the individual and the family.


Assist in developing health values of regimen adherencebefore the infant’s birth through emphasis of theseaspects in childbirth education classes.

Allow for the infant or child’s schedule in appointmentscheduling (e.g., respect for naps, mealtimes). Involvethe family in planning care for the infant or child.

Provide appropriate criteria for monitoring follow-up ofthe infant or child’s status, especially in instance ofchronic condition, to also demarcate when to call doc-tor or case manager.

Reward progress in the appropriate manner for age anddevelopment.

Depending on needs of the infant or child, may, whenservices cannot be procured, require a change in loca-tion with the goal of seeking effective therapeutic regi-men services. This may depend on state and/or localfunding with referral on regional basis. Language oreducational needs must also be addressed.

Initiates idea of individual health management for child’shealth before birth. Allows sufficient time for parentsto incorporate these ideas.

Facilitates comfort for the child, parents, and health-careprovider. Demonstrates individuality and increaseslikelihood of regimen implementation.

Anticipatory specific planning and knowledge of condi-tion enhances self-management behaviors, therebyvaluing self-esteem and likelihood of continued appro-priate follow-up.

Reinforcement increases valuing for desired behaviors.

The weakest component of many communities relates tocare of the young, thus making consideration of thechild a critical component.

Women’s Health


Develop a sensitivity for cultural differences of women’sroles and the impact on their implementation of a ther-apeutic regimen.144

Encourage the family to share views of childbirth withhealth-care personnel through classes and inter-views.144

Demonstration of understanding of the patient’s cultureand inclusion of these differences in planning increasethe probability of effective management of the thera-peutic regimen.

The health-care worker needs to be aware of how culturalbeliefs can impact the care of the new mother and hernewborn. Understanding the cultural beliefs of thepatient will help the health-care provider to plan care

Refer the patient and/or family to appropriate follow-uppersonnel (e.g., nurse practitioner, visiting nurse serv-ice, social service, or transportation service). Makereferral at least 3 days prior to discharge.

Request follow-up personnel to remind the patient ofappointments via card or telephone.

When discharge is imminent, transfer responsibility ofself-care to patient. Supervise performance, critique,and reteach as necessary.

Have the patient and significant others restate principlesat least three interactions prior to discharge.

Allows time for home care assessment and initiation ofservice.

Shares the responsibility for implementing the regimen,and demonstrates the importance attached to follow-upcare by those providers.

Allows sufficient practice time that provides immediatefeedback on skills, etc.

● N O T E : For Ineffective Management of Therapeutic Regimen (Community), seeHome Health.





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Women’s Health


Discuss with the family their traditions and taboos formother and baby during transitional period after child-birth. For example, in some Far Eastern cultures, themother does not touch the infant for several days afterbirth. The grandmother or aunts become the primarycaregivers for the infant.145,146

FamilyAssess the pregnant woman’s and her family’s perception

of the tasks of pregnancy complicated by high-risk fac-tors, such as premature rupture of membranes, prema-ture labor, maternal or fetal illness, and socioeconomichardships.145,146

Encourage the family to share concerns of the changesand restrictions on family lifestyle as a result of thehigh-risk pregnancy. (Example: Restrictions on preg-nant woman involving changes in homemaking, child-rearing, sexuality, social and recreational activities,disruptions in career, and financial commitments.) Helpthe family identify community agencies and resourcesthat can assist them to better follow the treatmentregimen.

CommunityInform appropriate agencies when new mothers (parents)

exhibit signs and symptoms of nonattachment to theirnewborn, substance abuse, homelessness, and dysfunc-tional family dynamics that could result in violence orneglect.147–149

Refer clients to appropriate community agencies (homevisiting nurses, public health nurses, child protectiveagencies, etc.) to provide new mothers and their infantstransitional care during postpartum period (particularlyafter early discharge).

in a manner that will insure the safety of both motherand infant, as well as gain compliance from thefamily.144

Increases patient satisfaction and compliance, as well asallowing the childbirth instructor and nursing personnelto plan with the patient and family appropriate careduring childbearing.

Provides basis for plan of care and allows the family tomake informed choices about care needs during andafter pregnancy.

Allows caregivers to determine importance of compliancewith treatment regimen to the family and to refer themto the proper resources.

Allows for appropriate support and follow-up for the newmother and her newborn infant.

Ensures smooth, safe transition for new mother and herfamily into parenting roles. Ensures physical and psy-chological stability for the new mother and her infant.Provides continuity of care from the hospital to thehome to the primary caregiver (physician, advancedpractice nurse, etc.).

Mental Health

● N O T E : It is important to remember that the mental health client is influenced by alarger social system and that this social system plays a crucial role in the client’s ongo-ing participation with the health-care team. The conceptualization that may be most use-ful in intervention and assessment of the client who does not follow the recommendationsof the health-care team in this area may be system persistence. Hoffman148 uses this con-cept to communicate the idea that the system is signaling that it desires to continue in itspresent manner of organization. This could present a situation in which the individual



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client indicates to the health-care team that he or she desires change, and yet change isnot demonstrated because of the constraints placed on the individual by the larger socialsystem (i.e., the family). This places the responsibility on the nurse to initiate a compre-hensive assessment of the client system when the diagnosis of Ineffective Management ofTherapeutic Regimen or Noncompliance is considered.


Involve the client system in discussions on the treatmentplan. This should include:

• Family• Individuals the client identifies as important in making

decisions related to health (e.g., cultural healers, socialinstitutions such as probation officers, public welfareworkers, officials in the school system, etc.)

Discuss with the family their perception of the currentsituation. This should include each family member, andeach should be given an opportunity to present his orher perspective. Questions to ask the family include:

• What do you think is the difficulty here?• Who is most affected by the current situation?• Who is least affected?• What have you done that has helped the most?• The least?• What happened when you tried to work on the situa-

tion?• What has changed in the family since the beginning of

the current situation?• What is the best advice you have received about this

situation?• What is the worst?

For further guidance in this process, refer to Wright andLeahey.69

Discuss with the identified system those factors thatinhibit system reorganization:

• Knowledge and skills related to necessary change• Resources available• Ability to use these resources• Belief system about treatment plan• Cultural values related to the treatment plan

Discuss with the system involvement of other systemssuch as social services, school systems, and health-careproviders in the family situation.

Assist the system in making the appropriate adjustmentsin system organization. Note the specific type of assis-tance the system requests here with the nursing actionsneeded identified.

Enhance, with positive reinforcement, current patternsthat facilitate system reorganization. Note the type ofpositive reinforcers to be utilized and behaviors to bereinforced here.

Role model effective communication by:

Promotes the client’s perceived control and increasespotential for the client’s involvement in the treatmentplan.69,88,143

Communicates respect of the family and their experienceof the situation, which promotes the development of atrusting relationship. Provides information about thefamily’s strengths, and provides the nurse with anopportunity to support these strengths in a manner thatwill facilitate the development of treatment programthat the family will implement.69,88,143

Recognition of those factors that inhibit change can facil-itate the development of a plan that eliminates theseproblems.

Larger systems often impose “rules” on families thatmaintain the larger system by sacrificing the families’coping abilities or becoming overinvolved to thedegree that families feel in a one-down position. Theprimary “rule” blames the family for problems.69

Affirms and promotes client’s strengths.61

Models for the family effective communication that canenhance their problem-solving abilities.69




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Mental Health


• Seeking clarification• Demonstrating respect for individual, family members,

and the family system• Listening to expression of thoughts and feelings• Setting clear limits• Being consistent• Communicating with the individual being addressed in

a clear manner• Encouraging sharing of information among appropriate

system subgroups

Demonstrate an understanding of the complexity of fam-ily problems by:

• Not taking sides in family problem solving• Providing alternative explanations of behavior patterns

that recognize the contributions of all persons involvedin the situation, including health-care providers, ifappropriate.

Make small changes in those patterns that inhibit systemchanges. For example, ask the client to talk with thefamily in the group room instead of in an open publicarea on the unit, or ask the client who washes his orher hands frequently to use a special soap and toweland then gradually introduce more changes in thepatterns.

Advise the client to make changes slowly. It is importantnot to expect too much too soon.

Provide the appropriate positive verbal feedback to allparts of the system involved in assisting with thechanges. It is important not to focus on the demonstra-tion of old patterns of behavior at this time. The small-est change should be recognized.

Develop goals with the family that are based on the dataobtained in the assessment. These goals should be spe-cific and behavioral in nature.

Provide positive reinforcement to families for thestrengths observed during the assessment and subse-quent interviews.

Encourage communication between family members by:• Having family members discuss alternative solutions

and goal setting.• Having each family member indicate how he or she

might contribute to resolution of the concerns.• Having family members identify strengths of one

another and how these can contribute to the resolutionof the situation.

Promotes the development of a trusting relationship whiledeveloping a positive orientation.61,69

Promotes the client’s control and provides realistic,achievable goals for the client, thus preserving self-esteem when change can be accomplished.61

Increases self-esteem and increases desire to continuethose behaviors that elicit this response.69,139

Promotes the family’s sense of control and the develop-ment of a trusting relationship by communicatingrespect for the client system. Accomplishment of goalsprovides positive reinforcement, which motivates con-tinued behavior and enhances self-esteem.61,69

Positive reinforcement motivates continued behavior andenhances self-esteem.69

Assists the family in developing problem-solving skillsthat will serve in future situations, and promoteshealthy family functioning.69



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Develop teaching plan to provide the family with infor-mation that will enhance their problem solving. Notethe content and schedule for this plan here.

Provide opportunities for the expression of a range ofaffect; this can mean having the family discuss situa-tions that promote laughing and crying together.Express to the family that their emotional experiencesare normal.

Contract with the family for specific behavioral home-work assignments that will be implemented before thenext meeting. These should be concrete and involveonly minor changes in the family’s normal patterns.For example, have them start with calling a resourcefor the information they may need to do something dif-ferent. If it is difficult for the family to accomplishthese tasks, the family system may be having unusualproblems with the change process and should bereferred to an advanced practitioner for further care.

If the task is not completed, do not chastise the family.Indicate that the nurse misjudged the complexity of thetask, and assess what made it difficult for the family tocomplete the task. Develop a new, less complex taskbased on this information. If the nurse and family con-tinue to have difficulty developing a plan of coopera-tion, a referral may need to be made to a nurse withadvanced training in family systems work. Promotespositive orientation and recognizes that the develop-ment of change strategies is an interactive processbetween the family and the health-care system.61,69

Communicate the plan to all members of the health-careteam.

Refer the family to community resources for continuedsupport. Assist family in making these contacts bydeveloping a specific plan. [Note the specific plan herewith the types of support needed.]

Develop with the family opportunities for them to havetime together and in various subgroupings (parents,parents with children, children) that involve activitiesother than those directly related to the current problem.This could include respite activities, family play time,relaxation, and other stress reduction activities. Notethis plan here.

Before termination, praise the family’s accomplishments.Give the family credit for the change.

Lack of information about the situation can interfere withproblem solving.69

Validates family members’ emotions and helps identifyappropriateness of their affective responses. Persistent,intense emotions can inhibit problem solving.69

Normalizing decreases sense of isolation and assists inmaking connections between family members.69

Suggesting specific tasks can provide the family with newways to interact that can improve problem solving.69

Promotes continuity of care and builds trust.

Community resources can provide ongoing support. Aspecific plan increases opportunities for success.61,69

Provides families with positive experiences with oneanother and opportunities to rebuild resources forcoping. Also assists them in developing a broaderidentity of the family. They are more than the pro-blem or illness.61,69

Reinforces family’s strengths and promotes self-esteem.Reminds family of the new skills they haveacquired.61,69


● N O T E : Refer to Home Health for primary interventions for Ineffective Managementof Therapeutic Regimen (Community). The primary agencies that are available to assistwith community mental health resources are the Mental Health Association and NationalAlliance for the Mentally Ill (NAMI). NAMI publishes a journal titled Innovations &Research. Both these associations open their membership to professionals, consumers,families of consumers, and members of the community interested in mental health issues.The purpose of these organizations is to provide community resources and support formental health consumers and their families and advocate for mental health consumers.




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Home Health


Assist the client, family, or community to delineate fac-tors contributing to ineffective therapeutic regimenmanagement by helping them to assess:

• Level of knowledge and skill related to treatment plan• Resources available to meet treatment plan objectives• Appropriate use of resources to meet treatment plan

objectives• Complexity of treatment plan• Current response to treatment plan• Use of nonprescribed interventions• Barriers to adherence to prescribed plan or medication

Involve the client, family, and community in planning,implementing, and promoting the treatment plan.147,148

Barriers and facilitators to ineffective management can bealtered to improve outcomes.

Involvement increases motivation and improves the prob-ability of success.


Gerontic Health

Refer to the Adult Health section for list of potential/actual factors present that may impede use of therapeuticregimen plan.


Refer to mental health specialist to rule out depression.

Refer to community resources.

Establish communication link with primary caregiver andfamily.

Advise family members of availability of managed careresources in the community where older client resides.

Provide follow-up support via home visits and telephonecontacts.

Assist caregivers in establishing and meeting their needs.

Review with the client and family the therapeuticregimen.

Provide multisensory (written, computer, audio) informa-tion on therapeutic regimen to assist client and care-giver in adhering to regimen.

Incorporate a variety of local, regional, or state socialservices to ensure that needed information about theregimen is available to older patients.

Identify older community leaders, via age-related groupsor associations, who can identify strengths or weak-nesses of the community (such as senior citizen centermembers, church groups, and support groups focusedon problems common to older adults).

Depression in the elderly is frequently underdiagnosedand undertreated.

The older patient may have concerns related to availabil-ity of support systems, costs of medication, and avail-ability of transportation. Use of already availablecommunity resources provides a long-term, cost-effective support system.

Family members may not be geographically available.

Provides care options for family to consider.

Presents opportunities for continued problem solving andincreasing trust.

Enables continuation of care while decreasing the poten-tial for burnout.

Helps determine possible areas of difficulty for client orcaregiver.

Provides quick access to information for the caregiver orclient.

Information flow may be impeded because of temporaryrelocation or social isolation.

Peer or cohort influences may assist in identifying andpromoting problem solving.



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• Assisting with family conferences.• Coordinating mutual goal setting.• Promoting increased communication.• Assigning family members specific tasks as appropriate

to assist in maintaining the therapeutic regimen plan(e.g., support person for patient, transportation, or com-panionship in meeting mutual goals).

• Identifying deficits in community resources.• Identifying appropriate community resources.• Utilizing population surveillance to detect changes in

illness patterns for the community.

Support the client, family, or community in eliminatingbarriers to implementing the regimen by:

• Providing for privacy.• Referring to community services (e.g., church, home

health volunteer, transportation service, or financialassistance).

• Alerting other health-care providers and social servicepersonnel of the problem that long waiting periods create.

• Providing for interpreters and for community-basedlanguage classes for English speakers to learn otherlanguages as well as for non-English speakers to learnEnglish.

• Identifying community leaders to develop coalitions toaddress the problems identified.

• Serving as social activist to encourage necessary par-ticipants to complete their tasks. This may include fund-raising, testifying before governing bodies, or coordi-nating efforts of several groups and organizations.

Assign one health-care provider or social service worker,as much as possible, to provide continuity in care pro-vision.

Assist health-care providers and social service workers tounderstand the destructive nature of noncompliance inchronic illness.148

Make timely telephone calls to clients to discuss care(e.g., 1 day after being seen in clinic for minor acuteinfection, or weekly or monthly on a routine schedulefor chronically ill person).148

Collaborate with other health-care professionals andsocial service workers to reduce the number and vari-ety of medications and treatments for chronically illclients.149–151

Reteach the client and family appropriate therapeuticactivities as the need arises.

Identify unmet needs of the community.

Involve community leaders and representative samplingof the community population in focus groups to iden-tify issues and to develop action plan to meet theunmet needs.

Many barriers are institutional and can be eliminated orreduced.

Continuity of care provides a means for effective problemsolving and early identification of problems.

Provides motivation for health-care providers to takeappropriate action when noncompliance is a problem.

Follow-up with clients reinforces positive behaviors andmay aid in early identification of problems. Follow-upalso implies support of health-care professionals.

Complex medication and treatment regimens may be dif-ficult for some clients to adhere to.

Reinforcement of information and continued assistancemay be required to improve implementation of thetherapeutic regimen.150

Accurate community needs assessment provides data toset community goals.

Collaboration among community leaders and citizensprovides support for long-term change





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MANAGEMENT, READINESSFOR ENHANCED THERAPEUTICREGIMEN

DEFINITION44

A pattern of regulating and integrating into daily living aprogram(s) for treatment of illness and its sequelae that isboth sufficient for meeting health-related goals and that canalso be strengthened.


1. Expresses desire to manage the treatment of illness andprevention of sequelae.

2. Choices of daily living are appropriate for meeting thegoals of treatment or prevention.

3. Expresses little to no difficulty with regulation/integration of one or more prescribed regimens

for the treatment of illness or prevention of com-plications.

4. Describes reduction of risk factors for progressionof illness and sequelae.

5. No unexpected acceleration of illness symptoms.

EXPECTED OUTCOME

The client will demonstrate enhanced management of theirtherapeutic regimen by [date].

TARGET DATES44

Client education and support are key interventions forReadiness for Enhanced Therapeutic Regimen. Since theclient is already demonstrating positive behaviors, it is rec-ommended that target dates be no further than 3 days fromthe date of initial diagnosis.


Home Health


Identify resources available and those needed to imple-ment action plan.

Create marketing plan to disseminate information andgenerate interest in plan.

Foster community partnerships to ensure the continuationof the plan.

Appropriate use of existing resources. Provides directionfor development of needed resources.

Communication of the plan is necessary to sustain inter-est and increase participation.

Long-term maintenance of the plan will require commit-ment and collaboration among many groups.


Adult Health


Initially, spend 30 minutes talking with client about theirunderstanding of their current health situation, pre-scribed regimen, and perceived responsibility regardingmanagement. Use language the client can understand

Provide a quiet environment for instruction. Ensure thatthe patient is well rested, pain free, and not under theinfluence of medications that alter cognition. Postponeteaching when patient’s condition, or the environment,does not promote focus on the content.

Identify key decision maker in client’s system based oncultural norms.

Spend [number] minutes 2 times a day discussing withclient their goals and methods they perceive wouldassist with goal achievement.

Allows the nurse to tailor teaching according tothe patient’s capacity to understand health-careinformation.152

Information will be better retained when the patient isable to adequately focus on instruction.


Readiness for Enhanced Therapeutic Regimen Management 93

••••••

Have patient identify the rewards for goal achievement.

Have patient identify their preferred and most effectiveway of learning (e.g., visual, auditory, or participatory)

Spend 15 minutes one time per day reviewing the planwith the client and providing an opportunity for ques-tions. Discuss with client rationale for various compo-nents of plan.

Have patient verbalize plan and ensure that patient’sunderstanding is congruent achieving therapeutic goal

Identify and secure adequate post-discharge support sys-tem. This could include community agencies, familyand friends.88,153

Appropriate teaching methods enhance transfer of infor-mation.

Imparts relevancy to the goal.

Child Health


Assess for all possible contributing factors related toinfant or child such as new or ongoing health/safetyneeds that comprise the therapeutic regimen.

Assess for caregiver’s (or child’s as appropriate) currentknowledge for therapeutic regimen.

Assess the caregiver’s and/or child’s priorities inlearning.

Provide environmental privacy and freedom from inter-ruption with pediatric-appropriate setting if child isalso included.

Utilize basic knowledge/developmental level language forchild in teaching.

Offer time for question/answer with examples to generatevalidation of knowledge.

Provide appropriate resource materials and creative devel-opmentally appropriate teaching aids (e.g., puppets).

Assist in development of plan for care calendar and filefor maintaining important resources.

Provides the most realistic basis for care.

Serves as a basis for validation and clarification of cur-rent knowledge and best plan for how to begin to assistin plan.

Provides mutual planning basis with respect for clientinput.

Offers a therapeutic milieu for learning.

Honors the caregiver/child’s ability to best understandplan.

Reinforcement of learning in a timely manner createslikelihood for retention.

Provides greater likelihood of learning.

Offers reinforcement and ability to remember access tohealth-care providers and follow-up.

Women’s Health


Women’s health follows the patterns, interventions andrationales of the Adult Health section. The followingcomments are specifically related to diseases that occurin women and/or diseases with a high incidence amongthe female population.

Discuss with women the effect of environmentallyacquired diseases and how to reduce exposure to envi-ronmental toxins. Provide them with information abouthazardous substances, perform risk assessment, andcollaborate with community agencies. Work with legis-lators to pass and enforce environmentally related leg-islation.154

Usually women of poor economic and minority classesare those exposed to environmental toxins. Substandardhousing, exposure to “dump sites” or exposure to envi-ronmental disaster sites (such as New Orleans’ NinthWard after hurricane Katrina).154





••••••


Women’s Health


Discuss the dangers of smoking and the effects of secondhand smoke on those about them (families, children,co-workers, etc). Guide them to programs for smokingcessation not only during pregnancy, but for all lifecycles.

Discuss alternatives to reducing symptoms of premen-strual syndrome. Lifestyle changes to include exerciseand good nutrition. Refer to classes to help decreasestress and provide emotional support.

Agricultural pesticides have been directly linked withbirth defects and some causal effects upon pregnancy,such as an increased incidence of PIH in agriculturalareas of the country.154

Smoking has been identified as the most hazardous expo-sure that women today face. Even if the individualdoes not smoke, exposure to second hand smoke canlead to menstrual cycle irregularities, osteoporosis,decreased fertility and lung cancer.155

Ninety-seven percent of women are affected by premen-strual syndrome at some point in their life.155–157

Mental Health


Spend 30 minutes once a day discussing client’s percep-tion of current situation and life/personal goals.

• Use open-ended questions and reflective listening• Let the client be the expert• Do not provide advice

Discuss client’s needs and resources necessary to supportongoing care

Reflect to client nurse’s understandings of the client’ssolutions and goals

Summarize the solutions and goals that the clientidentified

Develop a schedule for positive reinforcement when goalsare attained. Note the reinforcers and schedule of rein-forcement here.

Discuss with client sources of social support.• Schedule meeting with client and social support sys-

tem. [Note the date and time of that meeting here.]• Spend 1 hour one time per week meeting with client

and social support system to focus on:• With client’s permission educate support system about

client’s health-care needsModel communication and assist support system in devel-

oping positive communication skills

Include the client in group therapy to provide positiverole models and peer support and to permit assessmentof goals and exposure to differing problem solutions.

Provide client with information that will facilitate contactwith health-care team.

Schedule regular contact with the client to provide posi-tive reinforcement for their efforts and refer to commu-nity support systems before discharge.

Behavior change that is developed with the client usingthe client’s identified needs and co-evolved solutionsimproves outcomes.84–86


Social support improves health outcomes.88,153

Group provides opportunities to relate and react to otherswhile exploring behavior with each other.87

Ongoing support from the health-care team facilitatesadherence to therapeutic regimens.69,84,158


Readiness for Enhanced Therapeutic Regimen Management 95

••••••

Gerontic Health


Determine the client’s existing knowledge regarding thetherapeutic regimen.

Determine the client’s priorities for learning.




Present small units of information, with repetition, andencourage the patient to use cues that enhance abilityto recall information.


This allows the nurse to focus on strengths and existingknowledge and also assists in determining knowledgedeficits or misunderstandings.

Client involvement in the learning process facilitatessuccess.

Reduces anxiety and promotes a nondistracting environ-ment to enhance learning.





Home Health


Assess the client and family’s understanding of the cur-rent therapeutic regimen.

Assist the client/family in the development of a therapeu-tic network to include informal relationships withinformal structures in the nuclear family to selectlaypersons and professionals.174

Educate the client/family about risk factors and preven-tion for progression of their illness and sequelae.

Assist the client and family to identify home and work-place factors that can be modified to promote healthmaintenance (e.g., ramps instead of steps, eliminationof throw rugs, use of safety rails in showers, and main-tenance of a nonsmoking environment).92,93

Identifies potential misunderstanding or knowledgedeficit.

Enhances the support and educational resources of thefamily/client.

Involvement improves motivation and improves the out-come. Self-care is enhanced.


• Schedule time for the client to talk with communitysupport systems before discharge.

Discuss with client potential problems that might ariseand develop plans to adjust self-care as necessary.

Normalize times when client’s adherence to the therapeu-tic regimen is not perfect and schedule “safe holidays”from perfect adherence.

Provide client with educational materials.

Provide materials that address client’s best learning mode(auditory/visual) and at client’s level of understanding(proper reading level). [Note client’s reading level here.]

Prevents client burnout and enhances self-esteem.Planned relapse becomes no relapse.69

Provides self–care information that is readily accessibleto the client.84





••••••


Home Health



• Helping to establish family conferences to discussstrategies for meeting client health maintenance needs.

• Engaging in mutual goal setting with client and family.Encourage the client/family to establish goals for theirown involvement in managing the therapeutic regimen.

• Assisting family members in acquiring family or com-munity-based assistance for specified tasks as appropri-ate (e.g., cooking, cleaning, transportation,companionship, or support person for exercise program).

• Teach the family and caregivers about disease manage-ment for existing illness:


over-the-counter medications.• Reporting the use of over-the-counter remedies, herbal

supplements and medicines to the health-care provider.• Wound care as appropriate. Prevention of skin break-

down for clients with illnesses contributing to immo-bility.


• Relaxation techniques• Nutritional habits to maintain optimal weight and

physical strength.• Techniques for developing and strengthening support

networks (e.g., communication techniques or mutualgoal setting).

• Physical exercise to increase flexibility, cardiovascularconditioning, and physical strength and endurance.94

• Evaluation of occupational conditions92

• Control of harmful habit, such as substance abuse• Therapeutic value of pets95




PERIOPERATIVE-POSITIONINGINJURY, RISK FOR

DEFINITION44

A state in which the client is at risk for injury as a resultof the environmental conditions found in the perioperativesetting.


1. Disorientation2. Edema3. Emaciation

4. Immobilization5. Muscle weakness6. Obesity7. Sensory or perceptual disturbances due to anesthesia

RELATED FACTORS44

The risk factors also serve as the related factors.


1. Any condition requiring surgical intervention2. Peripheral vascular disease3. Diabetes mellitus4. Malnutrition


Perioperative-Positioning Injury, Risk For 97

••••••

5. Arthritis deformans6. Dementias, such as Alzheimer’s disease or multi-infarct

EXPECTED OUTCOME

Will remain free from any signs or symptoms of periopera-tive-positioning injury by [date].

TARGET DATES

Because of the emergency nature of this diagnosis, targetdates should be set in terms of hours for the first 2 dayspostoperatively.


Risk for InjuryThis diagnosis is broader based than Risk forPerioperative-Positioning Injury. The latter would beused only when surgery is involved.

Risk for Peripheral Neurovascular DysfunctionThis diagnosis is broader based than Risk forPerioperative-Positioning Injury. A comparison of riskfactors documents a wider variety of risk factors forperipheral neurovascular dysfunction.


Adult Health


General Principles (Generally Applies to All Positions,Including Supine)

Keep siderails up on stretcher.

The patient should be in a comfortable position whetherawake or asleep; ensure that operating room (OR) bedis dry and free from wrinkles.

Length of operative procedure should always be consid-ered in positioning and supporting patient during theoperation.

Provide adequate exposure of the operative site.

Maintain good anatomic alignment. Pad bony promi-nences and pressure points.

Ensure good respiration with no restrictions.

Nerves should be protected—arms, hands, legs, ankles,and feet; use a footboard.

The elderly, very thin, or obese patients should have spe-cial consideration; assess nutritional status, level ofhydration, vascular disease, etc.

Check mobility and range of motion prior to positioning.Note any physical abnormalities and/or injuries andhow they may affect the proposed position.

Move the patient only when anesthetist indicates patientcan be moved.

Have a sufficient number of people available to move thepatient safely or utilize appropriate transfer devices.

Ensure that no metal is touching the patient.

The dispersion pad should be on a fatty area (e.g., mid toupper thigh, depending on operative site). Recheck dis-persion pad if patient has to be repositioned.


Prevents softening of the skin and indentations of theskin.

Certain complications can arise with extended length ofoperation (e.g., low back pain for patient in supineposition, or pressure on heels and/or toes from drapes).

Prevents impaired circulation, awkward position, orundue pressure.

Avoids respiratory complications and assists in providinggood oxygenation.

Maintains alignment; relieves pressure.

Reduces the risk of complication.

Avoids unnecessary strain on already compromisedjoints, etc.

Avoids startling semiconscious patient and provides basicsafety.

Ensures patient safety and prevents shearing forces onskin

Reduces pressure risk and risk of injury if cautery isused.





••••••


Adult Health


Place arms at right angles to the patient. Do not hyperex-tend the arms. Secure the arms with a restraint aroundthe wrist.

Place the safety belt above the patient’s knees (dependingon operative site).

Ensure that all supports are padded.

Specific PositionsLithotomy

Raise or lower legs at the same time.

Lower legs, slowly at the same time.

Adjust height of stirrups to fit the patient’s legs.

Be sure that no part of the legs touch metal.

Cover stirrups with linen or place long leg booties on thepatient’s legs (up to mid thigh).

Pad popliteal space.

Ensure that the patient’s buttocks are over lower break intable.

Nephro or Thoracic Surgery

Move the patient slowly and carefully, as a unit; have suf-ficient assistance.

The patient will be on side over the middle break of thetable.

Position lower arm at a 90-degree angle away from body.

Place upper arm parallel to lower arm on a separate andhigh armboard or straight above the head. Restrain asneeded. Protect nerves and muscles.

Support the patient’s sides with padded kidney rests.

Bend bottom leg 45 to 90 degrees. Top leg should bestraight.

Place pillow(s) between knees and legs and feet

Jacksonian (Modified Knee–Chest)

Avoids strain on arms.

Avoids compromising circulation in popliteal area.


Reduces strain on hip joints.

Prevents electrical burns.

Protects nerves and circulation.

Basic safety measure.

Facilitates respiration; maintains circulation.

Provides support for side and back.

Stabilizes the patient.

Protects pressure points.

● N O T E : Patient will probably be put to sleep on the stretcher and then rolled ontothe OR table.

● N O T E : Patient will probably be put to sleep on the stretcher and then rolled onto aback frame. This allows the back to be hyperextended and supports the chest for goodrespiration. Actions are the same as for Jacksonian position except:

Have sufficient assistance to move the patient.

Extend arms on armboards above the head.

Place pillow under ankles.

Support chest.

Turn head to side; ensure an adequate airway.

Prone (Upper and Lower Back Surgery)


Facilitates respiration; maintains circulation.

Protects pressure points.

Stabilizes patient’s position.

Allows good expansion of chest and promotes gasexchange.


Perioperative-Positioning Injury, Risk For 99

••••••

Place pillows under upper chest, thighs, legs, ankles, andfeet.

Trendelenburg

Support shoulders with padded shoulder rests.

Avoids pressure and strains. Provides good anatomicalignment.

Provides stabilization of the patient’s position.

Child Health

● N O T E : Any procedure requiring prolonged stabilization in a fixed position places neonates and children at risk forthis diagnosis (e.g., ECMO [extracorporeal membranous oxygenation] with cannulation of major vessels requires fixedpositioning for several days to 1 week).

Safeguard the child with nursing actions relevant from Adult Health for positioning plus the following:


Monitor skin integrity from head to toes with specificattention to head, ears, elbows, back, and heels, orother body parts in direct contact with surface of mat-tress or lines from monitoring equipment.49

*Recognize the need for ongoing monitoring for infants,young children, or any client under the influence ofanesthesia regarding loss of sensation or cues of verbalnature to warn of pain/injury.

Decreases likelihood of impact of shearing forces orburns and demonstrates appropriate caution to diminishpossible injury.

Offers anticipatory planning for prevention and earlydetection of injury related to potential positionalfactors.

Infants and children with spina bifida (myelomeningo-cele) may have diminished neuro-sensation in legsand feet depending on the level of involvement.

Women’s Health

Same as for Adult Health except for the following:


Determine proper alignment and positioning of motherduring the cesarean section and any other procedure inwhich mother must lie on back. Place a wedge cushionunder the left buttock when positioning mother on sur-gical table.

Assist the mother’s chosen partner (support person) toprepare for the cesarean section by describing theevents that will take place, explaining his role andwhere he will sit (a stool or chair next to the mother’shead) during the surgery, and identifying who willassist him.

Enhances circulation and oxygen supply to the placentaand the fetus.159

Reassures and supports the partner (support person) dur-ing surgery, allowing him to be supportive to the preg-nant woman.

Mental Health

Nursing interventions and rationales for this diagnosis are the same as for Adult Health. Mental health clients who aremost commonly at risk for this diagnosis are those receiving electroconvulsive therapy (ECT) treatments.





••••••


Gerontic Health

In addition to the interventions for Adult Health, the following may be applied to the older client:


Monitor closely for signs of hypothermia, especially infrail elders.

Provide head and neck support that prevents head rotationor hyperextension.

Ensure adequate padding over pressure-prone areas.

Observe, especially intraoperatively, for external pressurecaused by leaning on patient.

Position extremities with caution.

Frail elders are at high risk for hypothermia as a result ofchanges associated with aging. Elimination of an anes-thetic agent may be reduced because of hypothermia.Older adults may have increased oxygen demand sec-ondary to shivering if hypothermia is nottreated.151,160,161

Hyperextension or rotation may cause vertebral circula-tory compromise in older patients.

Decreases potential for circulatory compromise as well asnervous system or skin injury in older patients at riskfor these problems.

Compromised circulation or increased skin pressure canresult in patient injury.

Older patients are at an increased risk for osteoporosisand, consequently, fractures.

Home Health


Begin preoperative teaching to the client and family assoon as possible prior to surgery. Include the need forearly ambulation, deep-breathing exercises, and ade-quate pain control. Reinforce teaching as needed post-operatively.

Instruct patient and family/caregivers about situations thatrequire immediate intervention from their health-careprovider:

• abrupt increase in temperature• changes in skin integrity• alterations in the patient’s level of consciousness

Involve the home caregiver in developing plan of care todecrease risk of complications.

Involvement of the client and family increases motiva-tion. Correct knowledge supports the behavior andassists in preventing complications.

Early intervention prevents exacerbation of com-plications.

Involvement in the planning increases motivation andsuccess of the intervention.

PROTECTION, INEFFECTIVE

DEFINITION44

The state in which an individual experiences a decrease inthe ability to guard the self from internal or external threatssuch as illness or injury.


1. Maladaptive stress response2. Neurosensory alterations3. Impaired healing

4. Deficient immunity5. Altered clotting6. Dyspnea7. Insomnia8. Weakness9. Restlessness

10. Pressure sore11. Perspiring12. Itching13. Immobility14. Chilling15. Cough


Protection, Ineffective 101

••••••

16. Fatigue17. Anorexia18. Disorientation

RELATED FACTORS44

1. Abnormal blood profiles (leukopenia, thrombocytopenia,anemia, coagulation)

2. Inadequate nutrition3. Extremes of age4. Drug therapies (antineoplastic, corticosteroid, immune,

anticoagulant, thrombolytic)5. Alcohol abuse6. Treatments (surgery, radiation)7. Disease such as cancer and immune disorders


1. AIDS2. Diabetes mellitus3. Anorexia nervosa4. Cancer5. Clotting disorders (e.g., disseminated intravascular coag-

ulation, thrombophlebitis, anticoagulant medications)

6. Substance abuse or dependence7. Any disorder requiring use of steroids

EXPECTED OUTCOME

Will return/demonstrate measures to increase self protectionby [date].

TARGET DATES44

Ineffective Protection is a long-lasting diagnosis. Therefore,a date to totally meet the expected outcome could be weeksand months. However, since the target date signals the timeto check progress, a date 3 days from the date of the origi-nal diagnosis would be appropriate.


Risk for InfectionThis diagnosis would most likely be a companiondiagnosis. Risk means the individual is not presentingthe actual defining characteristics of the diagnosis,but there are indications the diagnosis could develop.Ineffective Protection is an actual diagnosis.


Adult Health


Protect the patient from injury and infection. (See appro-priate nursing actions and rationales under the diag-noses Risk for Injury and Risk for Infection.)

Use standard precautions in caring for the patient.

Place the patient in protective isolation, but do not pro-mote an isolated feeling for the patient. Encourage fre-quent telephone calls and visits from significant others.

Check the patient at least every 30 minutes while awake.Spend 30 minutes with client every 2 hours on[odd/even] hour while awake to answer questions andprovide emotional support while in reverse isolation.Note times for these interactions here.

Monitor:• Vital signs, mucous membranes, skin integrity, and

response to medications at least once per shift.• Unexplained blood in the urine.• Prolonged bleeding after blood has been drawn or from

injection sites.

Protects the patient from infection or spread of infection.

Lessens sense of isolation and maintains therapeutic rela-tionship.

Allows comparison to baseline at admission and evalua-tion of effectiveness of therapy.




••••••


Adult Health


• Side effects of blood and blood products: Monitor forpossibility of blood reaction. Take vital signs every 15minutes, hour times an hour, then every 30 minutesuntil transfusion is completed. In the event of transfu-sion reaction, stop the transfusion immediately, main-tain IV line with saline, and notify physician whilemonitoring patient for further anaphylactic signs andsymptoms.

• Effects and side effects of steroids: Improved generalstatus, decreased inflammatory signs and symptomsversus untoward effects including bleeding, sodium(Na) or potassium (K) imbalance. Calculate and recordintake and output at least once per shift.

• Effects and side effects of antineoplastics, such as nau-sea, cardiac arrhythmias, extrapyramidal signs andsymptoms. These side effects vary according to thespecific agents used. Take vital signs every 5 to 10minutes during actual administration and use a cardiacmonitor.

• Signs and symptoms of infection such as lymphoidinterstitial pneumonia or recurrent oral candidiasis

Apply pressure after each injection and after removal ofIV needle.

Provide oral hygiene or assist the patient with oralhygiene at least 3 times per day, taking appropriateprecautions for vulnerable mucous membranes.

Provide body hygiene or assist the patient with bodyhygiene at least once daily at time of the patient’schoosing.

Measure and record intake and output at end of eachshift.

Provide the patient with food choices and portions thatwill facilitate their eating nutritious meals. Collaboratewith diet therapist regarding the patient’s likes, dis-likes, and planning for dietary needs after hospitaldischarge.

Collaborate with appropriate members of the health-careteam regarding therapeutic regimen

Teach the patient and significant others:• Medication administration• Signs and symptoms to be reported• Special laboratory or other procedures to be done at

home• Anticipatory safety needs• Routine daily care• Appropriate clean and sterile technique• Isolation or reverse-isolation technique• Common antigens and/or allergens and seasonal

variations

Assists in stopping of bleeding.

Prevents opportunistic infection.

Monitors effectiveness of bowel and bladder function.

Ensures balanced intake of necessary vitamins, minerals,etc., to assist in tissue repair. Assists in lesseningimpact of infections.

Gives guidelines for future therapeutic regimen as well asassessing effectiveness of current regimen.

Provides basic knowledge needed for the patient and fam-ily to make modifications necessitated by alteration inprotective mechanisms.


Protection, Ineffective 103

••••••

• How to avoid or reduce exposure to antigens and/orallergens (alteration of environment)

• Type and use of protective equipment• Standard precautions• Rationale for compliance with prescribed regimen• Resources available for assistance with health care,

legal questions, or ethical questions

Identify community resources for patient and family.Make referrals at least 3 days before discharge fromhospital.

Allows time for agencies to initiate service. Use of exist-ing community services is effective use of resources.

Child Health

● N O T E : Infants at risk for this diagnosis are premature infants, infants with familyhistory of hemophilia or sickle cell anemia, infants whose mothers have a history of drugabuse or HIV, and children who have histories of medication reaction. In infants espe-cially, incubation for HIV depends on acquisition time. The infant may be exposed anytime during pregnancy, but sero-con/retroversion to a negative HIV status may occur,with a later positive HIV status again. The more symptomatic the mother, the greater theeffect on the infant due to constant reinfection (in the infant). For infants whose mothersare HIV positive, 26 percent are HIV positive in the first 5 months of life, an additional24 percent are HIV positive by 12 months of life, and the remaining 50 percent are HIVpositive by 2 years of age. Key symptoms are intercurrent infection and weight loss.Other conditions noted include failure to thrive, hepatomegaly, cardiomegaly, lymphoidinterstitial pneumonia, chronic diarrhea, cardiomyopathy, encephalopathy, and oppor-tunistic infections. Even tuberculosis may be seen in these infants, with a tendency toprogress from primary to miliary phase. In these infants there may be disseminatedbacille Calmette-Guérin (BCG) infection. It is important to be aware of laboratory stud-ies requiring large amounts of blood to study the course of sero HIV status. This blooddrawing is problematic in the already depressed immune and reticuloendothelial systemsof these infants. It is imperative that these infants not be given live polio vaccine becauseof their HIV-positive status.


Maintain monitoring for:• Observable lesions of ecchymotic nature or evidence of

tendency toward bruising• Decreased absorption of nutrients (especially the pre-

mature infant because of the possibility of necrotizingenterocolitis)

Provide at least one 30 to 60 minute opportunity per dayfor the family to ventilate feelings about the specificillness of their child.

Teach the child and family essential care.

As applicable, exercise caution for any medications orblood products to be administered.

Provide diversionary therapy according to child’s status,developmental level, and interests.

Be aware of current frustration with use of DDC(dideoxycytidine) and AZT (zidovudine) in children.At this time, protocols dictate doses.

Essential monitoring to avoid overwhelming of child’ssystem by infection, etc.

Reduces anxiety, fear, and anger, and provides an oppor-tunity for teaching.

Basics of home care for child with diagnosis ofIneffective Protection.

Prevents boredom and restlessness and fosters continueddevelopment of child in spite of illness.

Avoid unrealistic hope. Ideally, toxicity is balancedagainst the need to reach therapeutic central nervoussystem (CNS) dosage levels.





••••••

Women’s Health


HELLP syndrome (a severe form of pregnancy-inducedhypertension): Monitor laboratory results for lowplatelets (less than 100,000/cc), elevated liver enzymes,elevated SGOT/SGPT, intravascular hemolysis, schisto-cytes or burr cells on peripheral smear, low hematocrit(Hct) (without evidence of significant blood loss), andhypertension.29,159

Other high-risk history in the mother such as history ofpreterm labor, chronic hypertension, sickle cell anemia,and other blood disorders.

Signs and symptoms of infection.

Mother’s history of drug abuse, alcohol abuse, HIV, ordomestic violence.

Understanding the laboratory values for a preeclampticmother progressing toward HELLP syndrome allowsthe health-care provider to prevent and/or begin earlytreatment of this dangerous variant of severepreeclampsia.

H � hemolysisEL � elevated liver enzymesLP � low platelets159

Allows nursing staff time and information to plan individ-ual care for the mother and her newborn infant.

Safety of the mother and the infant is of utmost impor-tance. Provides opportunity for assessment of homeenvironment and provision of assistance.


Child Health


Remind the family that current treatment for AIDS isonly palliative. Be sensitive to the unique nature of thishealth concern for all involved. Promote attention tothe need for:

• Spiritual and emotional support• Nutritional support• Treatment of HIV-related infections• Administration of IV immune globulin• Treatment of tumors and end organ failure• Chronic pain

Acknowledge potential loss of mother for the infant withHIV, and plan appropriately for foster care status asindicated.

Avoids unrealistic hope while providing knowledge andsupport necessary to deal with a fatal illness.

Anticipatory planning will assist in health maintenance inbest interest of infant in event of need for separationfrom the mother.

Mental Health

● N O T E : Clients receiving antipsychotic neuroleptic drugs are at risk for developmentof agranulocytosis. This can be a life-threatening side effect and usually occurs in thefirst 8 weeks of treatment. Any rapid onset of sore throat and fever should be immedi-ately reported and actively treated. Tricyclic antidepressants can cause blood dyscrasiaswith long-term therapy. Initial symptoms of these dyscrasias include fever, sore throat,and aching.


Immediately report the client’s complaint of sore throator development of temperature elevation to physician.Institute nursing actions for hyperthermia. (SeeChapter 3.)

Alterations could be symptoms of agranulocytosis orblood dyscrasias, which would place the client at riskfor infection. Prompt recognition and intervention pre-vent progression and improve client outcome.104


••••••Protection, Ineffective 105

Teach the client who has had this type of response toantipsychotic neuroleptics or tricyclic antidepressantsthat he or she should not take this drug again.

If the client is experiencing severe alterations in thoughtprocesses, provide one-to-one observation until mentalstatus improves or until the client can again participatein unit activities.

Refer to the nursing care plans for Sensory Perception:Distributed and Thought Processes: Disturbed for moredetailed plans of care.

Client safety is of primary importance. Provides opportu-nity for ongoing assessment of the quality of the con-tent of the client’s thought and provides ongoingreality orientation.

Gerontic Health

● N O T E : The older adult is subject to impaired protection due to age related changesin the immune system which include decreased resistance to bacterial, fungal, and viralinfections; increased risk of reactivating latent infections; absence of the classic signs ofinfection; changes in hypersensitivity responses; diminished response to vaccines; con-current chronic diseases and debilitation; institutionalization; increased incidence ofautoimmune disorders.


Monitor sensory status at each encounter. Ensure, if nec-essary, that sensory-enhancing aids (glasses, contacts,hearing aids) are clean and functioning.

Monitor for subtle signs of infection, such as new onsetof falls, incontinence, confusion, or decreased level offunction.

Teach the client to avoid soaps that may cause dry skin.

Initiate measures to maintain skin integrity such as:• Using pressure-relieving devices for use in chairs or

in bed• Ensuring frequent weight shifting to reduce pressure on

vulnerable areas (bony prominences)• Monitoring and documenting skin status with each con-

tact according to care setting and client condition• Avoiding shearing forces that may cause epidermal

damage• Prompting client and caregiver to change position fre-

quently to avoid skin integrity problems

Teach clients and/or caregivers need for AIDS testing asappropriate.

Monitor renal and hepatic function in older adults whoreceive antiretroviral therapy.

Assist the client in maintaining adequate hydration of2000 cc daily.

Assist the client in maintaining adequate vitamin intake,particularly vitamins A, C and E, zinc, and selenium.

Uncorrected sensory impairments may negatively impactthe communication process.

Changes in immune system with aging can causeincreased potential for infection. Infection may presentin an atypical manner in older adults.42

Dry skin predisposes to potential skin breakdown andloss of protective barrier against pathogens.162

Intact skin acts as a protective barrier against infection.162

AIDS is often undetected in older adults in the earlystages because of lack of knowledge about risk for thedisease and false assumptions that AIDS is not a dis-ease present in older adults.164,165

Antiretroviral therapy can further compromise kidney andliver function.

Adequate hydration status has a preventive effect.

These nutrients are known to assist in infectionprevention.





••••••


Home Health


Develop, with the client, family, and caregiver, plans fordealing with emergency situations, such as:

• Decision making regarding calling ambulance• Decision tree for calling nurse or physician

Assist the client and family to identify learning needssuch as:

• Universal precautions• How to disinfect surfaces contaminated with blood or

body fluids (use 1:10 solution of bleach)• Protective isolation• Proper handwashing• Use of separate razors, toothbrushes, eating utensils,

etc.• Proper cooking of food• Avoidance of pet excrement• Avoidance of others with infection• Skin care, oral hygiene, and wound care• Use of protective equipment• Signs and symptoms of infection, fluid and electrolyte

imbalance, malnutrition, pathologic changes in behav-ior, and underlying disease process

• CPR and first aid• Hazardous waste disposal (e.g., soiled dressings, nee-

dles, or chemotherapy vials)• Advanced directive (e.g., living wills and durable

power of attorney for health care)• Financial and/or estate planning• Symptom management and pain control• Administration of required medications• Nutrition• Care of catheters, IVs, respiratory therapy equip-

ment, etc.• Proper treatment of linens soiled with infectious matter• Environmental cleanliness

Assist the client and the family to identify resources tomeet identified learning needs.

Involve the client and family in planning and implement-ing environmental, social, and family adaptations toprotect the client.

Plan with the family and client for safe as well as mean-ingful activities according to the client’s level of func-tioning and interests.

Assist the client and family in lifestyle adjustments thatmay be required.

Advance planning improves the response and outcomesin crisis situations.

This action describes knowledge required to protect theclient and the family.

Hot water provides an effective means of destroyingmicroorganisms, and a temperature of at least 160�Ffor a minimum of 25 minutes is commonly recom-mended for hot-water washing. Chlorine bleach pro-vides an extra margin of safety. A total availablechlorine residual of 50 to 150 ppm is usually achievedduring the bleach cycle.98

Involvement of the client and family improves their abil-ity to identify resources and to function more inde-pendently.

Involvement of the client and family improves motivationand outcomes.

Provides for activity while protecting the client andfamily.

Lifestyle changes often require support.


Surgical Recovery, Delayed 107

••••••

SURGICAL RECOVERY, DELAYED

DEFINITION44

An extension of the number of postoperative days requiredfor individuals to initiate and perform on their own behalfactivities that maintain life, health, and well-being.


1. Evidence of interrupted healing of surgical area (e.g.,red, indurated, draining, immobile)

2. Loss of appetite with or without nausea3. Difficulty in moving about4. Requires help to complete self-care5. Fatigue6. Report of pain or discomfort7. Postpones resumption of work or employment

activities8. Perception that more time is needed to recover

RELATED FACTORS44

To be developed.


1. Any recent major surgeries2. Recent trauma requiring surgical intervention

EXPECTED OUTCOME

Surgical incision will show no signs or symptoms of delayedhealing by [date].

TARGET DATES

Because of multiple factors such as age, presence of chronicconditions, or a compromised immune system, the targetdate for this diagnosis could range from days to weeks. Anappropriate initial target date, to measure progress, would be3 days.


Risk for InfectionRisk for infection could be a companion diagnosisand would increase the probability of DelayedSurgical Recovery developing.

Ineffective Tissue PerfusionThis diagnosis could be the primary diagnosis,because any alteration in tissue perfusion to the oper-ative site could result in delayed healing.

Impaired Physical MobilityThis diagnosis could also be a companion diagnosisor could be a contributing factor to the developmentof Delayed Surgical Recovery. This diagnosis wouldinterfere with the necessary postoperative ambulation.


Adult Health


Assist patient in identifying perceived obstacles todelayed recovery.

Incorporate patient into plan of care and display goalsprominently in patient room.

Reduce obstacles to learning. Provide a stress free envi-ronment, provide ample pain control measures withoutimpeding mentation. [Note those actions needed by thenurse to facilitate client’s learning here.]

Protect the patient from injury and infection. Use stan-dard precautions.

Collaborate with diet therapist for in-depth dietary assess-ment and planning. Monitor the patient’s food and fluidintake daily.

Carefully plan activities of daily living and daily exerciseschedules with detailed input from the patient.Determine how to best foster future patterns that willmaintain optimal sleep–rest patterns without fatiguethrough planning ADLs with the patient and family.

Assist the patient with self-care as needed. Plan gradualincrease in activities over several days.

Gives visual substantiation toward goal attainment (IHIWeb site).

Stress, pain, etc. reduce receptivity to instruction.167

Protects patient from infection or spread of infection.

Adequate, balanced nutrition assists in healing and reduc-ing fatigue.

Realistic schedules based on the patient’s input promoteparticipation in activities and a sense of success.

Allows the patient to gradually increase strength and tol-erance for activities.




••••••


Adult Health


Promote rest at night. Note those things that assistsclient’s rest here.

Avoid sensory overload or sensory deprivation. Providediversional activities.

Address unresolved stressors by instructing the patient instress reduction techniques. Note those techniques tobe taught here.

• Have patient return—demonstrate at least once a daythrough day of discharge.

Assist the patient to develop coping skills:• Review past coping behaviors and success or lack of

success.• Help identify and practice new coping strategies.

• Challenge unrealistic assumptions or goals.

Turn, cough, and deep breathe every 2 hours on[odd/even] hour.

Incorporate passive or active ROM exercises as appropri-ate every 2 hours on [odd/even] hour.

Initiate early mobilization strategies

Protect with a sterile dressing for 24 to 48 hours. Washhands before and after dressing changes or any contactwith the surgical site, or when an incision dressingmust be changed. Use sterile technique, and educatethe patient and family regarding proper:

• Incision care, symptoms of SSI, and the need to reportsuch symptoms.

• Monitor for hyperglycemia• Assess cultural and religious norms.

• Collaborate with psychiatric nurse practitioner, ostomyor wound care management specialist as appropriateregarding care.

Increases quantity and quality of rest and sleep.

Sensory aspects can deplete energy stores. Diversionalactivities help prevent overload or deprivation byfocusing patient’s concentration on an activity he orshe personally enjoys.

Mental and physical stress greatly contributes to sense ofinability to resume ADLs and stimulates undesirableeffects from stress response.

Determines what has helped in the past, and determines ifthe measures are still useful.

Allows the patient to practice and become comfortablewith skills in a supportive environment.

Assists the patient to avoid placing extra stress on self.

Mobilizes static pulmonary secretions.

Promotes tissue perfusion and can benefit pulmonary sys-tem.168

Has been shown to improve oxygen saturation anddecrease length of stay.151

Hyperglycemia lends to decreased wound healing.Cultural and religious norms influence the perception of

“the sick role.”Collaboration helps to provide holistic care. Specialist

may help discover underlying events for delayed surgicalrecovery and assist in designing an alternate plan of care.

Child Health


Monitor for all contributing factors, such as diet, alteredorganic or pathophysiologic functions, medications,environmental issues, psychological components, andcircumstantial issues.

Determine appropriate treatment with attention to uniquestatus per client’s situation, with specific attention tomedications, formula or diet, and surgicalprocedure/expected recovery.

Thorough assessment will best offer ways to address fac-tors that are impeding healing.

Anticipatory planning provides holistic avenues to con-sider for recovery.


••••••Surgical Recovery, Delayed 109

Note specific treatment protocols to satisfy unique heal-ing or surgically related needs for client.

Reassess every 8 hours for progress in healing(wound color, tissue status, drainage, and allrelated parameters).

Reassess for potential additional delays of recovery asinitial delays are identified.

Assess for other nursing problems that may be identifiedas critical to resolution in relation to current surgicaldelay.

Unique protocols will best offer appropriate healing like-lihood when implemented per intended plan.

Frequent ongoing assessment provides feedback to assistin determination of success of plan versus need forconsideration of alternate modalities.

Primary delays in surgical recovery may contribute tolikelihood of delays to be noted later, with multipledelays made more likely to be noted before greatercomplications arise.

Multifactorial problems in recovery are best managed byseparation and identification according to known etiol-ogy and treatment.

Women’s Health

This nursing diagnosis pertains to women the same as to any other adult, with exception of the following:


After a Cesarean SectionMonitor abdomen at least every 4 hours (state times here)

for any distention, redness or swelling at incision site,tenderness, foul-smelling lochia, or vaginal discharge.

Wash hands each time before and after you or familymembers handle the baby.

Maternal delay in recovering can involve a longer separa-tion from the infant:

• Act as a liaison between the family, nursery, and themother.

• Keep the mother informed and reassured about herbaby.

If the mother is unable to care for the infant, develop aschedule in which the infant is brought to the mother’sroom for frequent visiting.

Let significant other or chosen family member care forthe infant in the mother’s room.

If unable to transport the infant to the mother, obtain pic-tures of infant and set them up where the mother canview them.

Involve other family members in the care of the infant.• Prepare the family to take the infant home without the

mother.• Teach the family, and have them return—demonstrate,

care and feeding of the infant.• If the mother desires to breast-feed:• Collaborate with physician regarding advisability of

breast-feeding.• Involve lactation consultant to assist mother in pump-

ing and• dumping milk if unable to use for infant, or• storing milk, if able to use, and sending home with

the family.

Monitor the patient for signs and symptoms of incisionaland/or puerperal infection.

Prevents development of nosocomial infection in theinfant.





••••••

Gerontic Health

● N O T E : The older adult undergoing surgical treatment, either elective or emergency,is at great risk for problems with delayed recovery. Age-related changes in numeroussystems and protective mechanisms increase the potential for complications pre-, intra-,and postoperatively. It is not uncommon for older adults to have a preexisting medicaldisease, atypical signs and symptoms of infection, cardiac or respiratory problems, andless ability to deal with stressors such as hypoxia, volume depletion, or volume overload.Gerontologic nursing groups are actively designing research-based protocols to ensure“best practices” in caring for older adults. The reader is referred to the work of NICHE(Nurses Improving the Care of the Hospitalized Elderly) at the Hartford Institute forGeriatric Nursing and the University of Iowa Research-Based Protocols developed bythe University of Iowa Gerontological Nursing Interventions Research Center(http://www.hartfordign.org/programs/niche/)129,130


Determine the client’s mental status upon admission, andmonitor the client for signs of acute confusion (delir-ium). Document results of mental status determinationsin the client’s record. The Mini-Mental State Exam byFolstein and/or the NEECHAM Confusion Scale aretools commonly used or recommended to determinemental status.

Initiate protocol (if available in your facility) for interven-tions addressing care of the acutely confused client ifmental status changes warrant such action.

Manage postoperative acute pain aggressively to assistclients in recovery from the effects of surgery. Teachclients and family or significant others the benefits ofadequate pain control in the recuperative process. Painmanagement can promote early ambulation, facilitateeffective coughing and deep breathing, and decreasepostoperative complications.

Plan caregiving activities that avoid stressing the clientdue to prolonged duration or intensity.

Monitor for evidence of poor wound healing.

Arrange for a nutrition consult if the client shows evi-dence of altered nutritional status.

Refer older adults for evaluation of possible depression,especially if declining functional ability is noted.

Older adults are at risk for developing acute confusionbecause of the multiple risk factors they experience(relocation, pain, physiologic changes associated withsurgical procedures).

Delays in determining the presence of acute confusionmay lead to extended hospital stays, decreases in func-tional status, and nursing home placement for olderadults.

Older adults and some health-care providers may haveconcerns regarding use of pain medication. Some olderadults may have fears of becoming addicted to medica-tions. Health-care providers may be reluctant to med-icate older adults because of concerns aboutoverdosing or oversedating older clients.153,154

Physiologic reserves are decreased with aging. Too manydemands can lead to increased fatigue and decreasedability to tolerate mobility efforts and postoperativeactivities to improve respiratory and cardiovascularstatus.

Medications, poor nutritional status, systemic disease,and a history of smoking can have a negative effect onthe normal wound repair response.155

Alterations in nutrition, such as protein–calorie malnutri-tion or nutrient deficiencies, can affect wound healing.

Older adults who have depressive symptoms have nega-tive postoperative outcomes.156,157


Mental Health

Nursing interventions and rationales for this diagnosis are the same as those for Adult Health.


Sudden Infant Death Syndrome, Risk For 111

••••••

Home Health


Educate the client, family members, and potential care-givers how to care for the wound appropriately andhave them demonstrate proper wound care.

Assist the client and caregivers in obtaining necessarysupplies for appropriate wound care.

Instruct the client and caregivers in signs and symptomsof infection, hemorrhage, and dehiscence, as well ashow and when to seek medical care.

Educate the client, family members, and potential care-givers of the importance of taking all antibiotics asprescribed until the regimen is complete.

Encourage the client to eat small frequent meals that arehigh in calories and protein.

Weigh the client twice weekly.

Encourage the client to identify times of day whenfatigue is worse, and space activities around the timeswhen they are less fatigued.

Assist the client in obtaining durable medical equipmentfor the home (e.g., bedside commodes and showerchairs) until the fatigue improves.

Encourage the client to rest before scheduled activities.

Encourage the client to participate in walking activity astolerated.

Encourage the client and caregivers to adhere to a round-the-clock analgesic regimen rather than using medica-tions on a prn basis until pain is controlled.

Actively listen to the client and family members’ con-cerns about delayed recovery and provide honestanswers about the client’s progress.

Assist the client in obtaining letters and/or documentationas needed for employers regarding extended recoverytime.

Allows the family to participate in care and preventsinfection or exacerbation of existing infection.

Maximizes the client and caregiver’s ability to provideappropriate wound care.


Treats existing infection and prevents possible super-infection.

Allows maximum nutrition without discomfort fromlarge meals.

Early identification of excessive weight loss can helpidentify complications such as dehydration.

Allows the client some control of activities.

Makes self-care activities less tiring.

May help avoid exacerbation of the fatigue.

Fatigue seems to show improvement with walkingprograms

Keeps pain at a tolerable level and avoids highs and lowsin pain intensity.

Allows verbalization of frustration and aids in realisticplanning for the future.

Helps eliminate a source of anxiety.

SUDDEN INFANT DEATHSYNDROME, RISK FOR

DEFINITION44

Presence of risk factors for sudden death of an infant under1 year of age.

RISK FACTORS44

Modifiable1. Infants placed to sleep in the prone or side lying position2. Prenatal and/or postnatal infant smoke exposure3. Infant overheating/overwrapping

4. Soft underlayment/loose articles in the sleepenvironment

5. Delayed or nonattendance of prenatal care

Potentially Modifiable1. Low birthweight2. Prematurity3. Young maternal age

Nonmodifiable1. Male gender2. Ethnicity (i.e., African American or Native American

race of mother)



••••••

3. Seasonality of SIDS deaths (higher in winter and fallmonths)

4. SIDS mortality peaks between infant age of 2 to4 months


1. Prematurity2. Low birthweight3. Young maternal age4. Late or absence of prenatal care5. Prenatal history of maternal smoking6. High-risk status of the neonate, esp. males

EXPECTED OUTCOME

Will identify risk factors [list] and at least one correctivemeasure for each risk by [date].

*The priority risk factor is assumed to be the need forputting infants to sleep on their back on non-soft bedding,free of pillows.


For many years, apnea was thought to be the predecessor ofSIDS, and home apnea monitors were considered effectiveas a means of preventing SIDS. Although the AmericanAcademy of Pediatrics acknowledges that home apnea mon-itors are being used widely, they do not recommend their useas a strategy to prevent SIDS. Monitors may be helpful toallow rapid recognition of apnea, airway obstruction, respi-ratory failure, interruption of supplemental oxygen supply,or failure of mechanical respiratory support in those infants

who have experienced an apparent life threatening event(ALTE) according to the Sudden Infant Death SyndromeTask Force of the American Academy of Pediatrics.173

The predominant hypothesis regarding the etiology ofSIDS remains that certain infants, for reasons yet to be deter-mined, may have a maldevelopment or delay in maturationof the brainstem neural network that accounts for arousaland influences the physiologic responses to life-threateningchallenges during sleep. The Task Force on SIDS recom-mends cautious consideration for modifying those riskswhich can be modified while recognizing there may be addi-tional factors to be considered by the pediatrician and health-care team in allowing for the best practice.173

TARGET DATES

A long-term goal of maintaining infant safety can be metby establishing short-term goals of parent/caregiver educa-tion. Short-term goals for parents/caregivers to verbalizeor demonstrate proper infant care should be establishedin terms of days or hours, ideally prior to discharge of theinfant.


Risk for Sudden Infant Death Syndrome is the mostappropriate diagnosis if the parents or infant care-givers verbalize less-than-adequate understanding ofinfant care or if potentially modifiable or nonmodifi-able risk factors are present.


Adult Health

The interventions for Child/Women’s Health apply to this population.

Child Health


Assess caregiver(s) readiness for learning to preventSIDS.

Provide educational materials to primary caregiver(s)to include the following as applicable. (Confirm thoseaspects that may be inappropriate with pediatricianor primary care provider.):

• Universal precautions• Place infant on back with pacifier from birth to

6 months of age.

Readiness offers cues for likelihood of effective learningas prevention education increases likelihood for reduc-tion of risk for SIDS to extent possible.173

Adheres to standards currently endorsed by the SIDSTask Force of the American Academy of Pediatrics.173

Assists in maintenance of airway.


••••••Sudden Infant Death Syndrome, Risk For 113

• Use of firm sleep mattress with basic sheet covering.Avoid placing soft materials such as pillows, quilts,comforters, or sheepskins under a sleeping infant.

• Avoid soft objects (such as stuffed animals) and loosebedding (no pillow-like bumper pads, instead use thin,fixed to crib bumper pads). Tuck blankets from chestlevel down or utilize sleep sacks designed to keepinfant warm but not constricted or head covering.

• Have infant’s crib in same room as caregiver(s) but noco-sleeping.

• Refrain from smoking; do not expose the infant tosecond-hand smoke.

• Consider offering a pacifier at nap time and bedtime.

• Do not reinsert pacifier once infant falls asleep.• If infant refuses pacifier, do not force infant to take it.• Pacifiers are to be free of any sweet solution.

• Pacifiers are to be cleaned often and replaced regularlyevery 3 to 4 weeks.

• For breast-fed infants, delay pacifier introduction until1 month of age

• Avoid overheating: infant to be lightly clothed for sleepwith room temperature maintained for adult with lightclothing-infant should not feel hot to the touch.

• Avoid commercial devices marketed to reduce the riskof SIDS including positional devices or rebreathingdevices.

• Do not use home monitors as a strategy for reducingthe risk of SIDS. Electronic respiratory and cardiacmonitors are suited to detect cardiorespiratory arrestand may be of value for home monitoring of thoseinfants deemed to be at risk for instability from a car-diorespiratory standpoint.

• If concurrent risk exists for apnea of infancy or prema-turity, caregiver(s) are taught basic CPR.

*May vary per institution or preference of pediatrician orneonatologist.

• Avoid possible development of positional plagio-cephaly (malshapen flatness of the occiput).

• Encourage tummy time while infant is awake and inclose observation.

• Avoid excessive time in carriers, car-seat carriers, orbouncers in which the occiput is pressured.

• Alternate position of head turning week by week andalternate crib position to provide alternate views to restof room.

*Special attention should be addressed to these compo-nents if neurologic injury or developmental delay ofthe infant is suspected.

Early referral for plagiocephaly is encouraged to helpavoid the need for surgery. In some instances, orthoticsmay help avoid surgical intervention.

Lessens likelihood of infant airway being obstructed sec-ondary to blanket or other surface bedding obstructingairway.

Lessens likelihood of objects or blankets coveringinfant’s face or obstructing the infant’s airway.

Risk of SIDS reduced and allows for close contact forfeeding and potential need for intervention.

Lessens irritants to reduce SIDS and numerous other res-piratory conditions.

Mechanism is unknown, but evidence is compelling forreducing risk of SIDS.

Same as above.Same as above.Lessens likelihood of infection with such organisms as

botulism as found in honey.Lessens likelihood of infection or likelihood of broken

pieces being aspirated by infant.Lessens likelihood of nipple confusion as breastfeeding is

established.Overheating is shown to be a risk factor for SIDS.

Efficacy or safety is not yet sufficiently upheld in studiesdone thus far.

Does not decrease the threat of SIDS.

Offers caregiver(s) sense of confidence for ability tointervene in instance of actual cardiorespiratory arrest.

Recommendations for alternative positioning and move-ment during waking time is likely to prevent the mal-shaping of the infant’s head while also fosteringappropriate motor development and time for interactionwith primary caregiver(s).





••••••


Child Health


Monitor primary caregiver for support need(s).

Teach caregiver(s) to maintain close observation of infantat all times.

Monitor caregiver’s ability to provide this care.

Teach caregiver(s) to utilize national and local resourcesfor additional support for education and support indealing with the risk for SIDS. National SIDSResource Center: http://www.sidscenter.org, AmericanSudden Infant Death Syndrome (SIDS) Institute.(http://www.sids.org)

Monitor for concurrent risk factors that place the mater-nal–infant dyad at increased likelihood for stressorsthat suggest other nursing needs, especially role strainand primary caregiving needs.

Monitor caregiver(s) compliance with plan for reductionof SIDS risk.

• Provide positive verbal reinforcement forprogress/identification of unmet preventive goals.

Remind caregiver(s) of need for other caregivers to com-ply with essential SIDS risk reduction measures, espe-cially day care and babysitters.

Provides backup to help value and support caregiver(s),esp. in instance of young age or those for whom sup-port is vital.

Maintains safe environment.

Provides support to strengthen knowledge and sense ofability to cope with reinforcement of basic risk reduc-ing principles for SIDS with shared sense of valuing.

Assists in secondary prevention of related problems.

Values the importance of compliance with SIDS riskreduction and offers confirmation of caregiver(s) abilityto demonstrate accuracy of techniques.

Ensures uniform risk reduction for SIDS to degreepossible.

Women’s Health


The education and advice recorded in the child healthsection apply to women’s health, as women are themajor caretakers of children. However all caregivers,whether grandparents, or other family members shouldbe aware how to comply with the essential SIDS riskreduction measures.

Care of self during the prenatal period can contributeto the reduction of the incidence of SIDS. Good nutri-tion, proper exercise, no smoking, no exposure tosecond-hand smoke, and no drug or alcohol useduring pregnancy.

The risk of SIDS is five to ten times greater in infants ofmothers who abused drugs during pregnancy. This isparticularly true of the infant who goes through with-drawal after birth.29

Mental Health

The interventions for Child/Women’s Health apply to this population.



••••••

Gerontic Health

This diagnosis does not apply to the aging population unless the infant caregiver is elderly. In such cases, the interventionsfor Child/Women’s Health would apply.

Home Health

The interventions for Child/Women’s Health would be applied in the home setting.

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3NUTRITIONAL–METABOLIC PATTERN

1. ADULT FAILURE TO THRIVE 1312. ASPIRATION, RISK FOR 1363. BODY TEMPERATURE, IMBALANCED, RISK FOR 1394. BREASTFEEDING, EFFECTIVE 1445. BREASTFEEDING, INEFFECTIVE 1486. BREASTFEEDING, INTERRUPTED 1527. DENTITION, IMPAIRED 1558. FLUID BALANCE, READINESS FOR ENHANCED 1589. FLUID VOLUME, DEFICIENT, RISK FOR AND ACTUAL 161

10. FLUID VOLUME, EXCESS 16711. FLUID VOLUME, IMBALANCED, RISK FOR 17312. HYPERTHERMIA 17613. HYPOTHERMIA 18214. INFANT FEEDING PATTERN, INEFFECTIVE 18615. NAUSEA 18916. NUTRITION, READINESS FOR ENHANCED 19217. NUTRITION, IMBALANCED, LESS THAN BODY

REQUIREMENTS 19418. NUTRITION, IMBALANCED, MORE THAN BODY

REQUIREMENTS, RISK FOR AND ACTUAL 20419. SWALLOWING, IMPAIRED 20920. THERMOREGULATION, INEFFECTIVE 21321. TISSUE INTEGRITY, IMPAIRED 216

A. Skin Integrity, Impaired, Risk for and ActualB. Oral Mucous Membrane, Impaired


PATTERN DESCRIPTION

The nutritional–metabolic pattern focuses on food and fluidintake, the body’s use of this intake (metabolism), and prob-lems that might influence intake. Problems in this patternmay have a physiologic, psychological, or sociologic base.Physiologic problems may be primary in nature, for example,vitamin deficiency, or they may arise secondary to anotherpathophysiologic state, such as a peptic ulcer. Psychologicalfactors, such as stress, may result in an alteration, such asovereating or anorexia nervosa, in the nutritional–metabolicpattern. Sociologic factors, for example, low income, inade-quate or unsafe storage, social isolation, and cultural foodpreferences, may result in an altered nutritional–metabolicstate.

According to the popular truism “You are what youeat,” what we eat is converted to our cellular structure andaffects its functioning. The nutritional–metabolic patternallows us to look at the whole of this relationship.

PATTERN ASSESSMENT

1. Weigh the patient. Is the patient’s weight beyondthe recommended range for his or her height, age,and sex?a. Yes (Imbalanced Nutrition, More Than Body

Requirements, Risk for or Actual; Fluid VolumeExcess; Imbalanced Body Temperature, Risk for;Imbalanced Fluid Volume, Risk for)

b. No (Nutrition, Readiness for Enhanced)2. Does the patient weigh less than the recommended range

for his or her height, age, and sex?a. Yes (Imbalanced Nutrition, Less Than Body

Requirements; Deficient Fluid Volume, Risk for orActual; Imbalanced Body Temperature, Risk for;Adult Failure to Thrive; Impaired Dentition)

b. No (Nutrition, Readiness for Enhanced)3. Have the patient describe a typical day’s intake of both

food and fluid, including snacks and the pattern of eat-ing. Is the patient’s food intake above the average for hisor her age, sex, height, weight, and activity level?a. Yes (Imbalanced Nutrition, More Than Body

Requirements, Risk for or Actual)b. No (Nutrition, Readiness for Enhanced)

4. Is the patient’s food intake below the average for his orher age, sex, height, weight, and activity level?a. Yes (Imbalanced Nutrition, Less Than Body

Requirements; Adult Failure to Thrive; ImpairedDentition)

b. No (Nutrition, Readiness for Enhanced)5. Is the patient’s fluid intake sufficient for his or her age,

sex, height, weight, activity level, and fluid output?a. Yes (Fluid Balance, Readiness for Enhanced)b. No (Deficient Fluid Volume, Risk for or Actual;

Imbalanced Body Temperature, Risk for; ImbalancedFluid Volume, Risk for)

6. Does the patient show evidence of edema?a. Yes (Fluid Volume Excess; Imbalanced Fluid

Volume, Risk for)b. No

7. Is the patient’s gag reflex present?a. Yesb. No (Impaired Swallowing; Risk for Aspiration)

8. Does the patient cough or choke during eating?a. Yes (Impaired Swallowing; Risk for Aspiration)b. No

9. Assess the patient’s mouth, eyes, and skin. Are theseassessments within normal limits (e.g., no lesions, sore-ness, or inflamed areas)?a. Yesb. No (Impaired Tissue Integrity; Impaired Oral

Mucous Membrane)10. Assess the patient’s teeth. Are teeth within normal lim-

its?a. Yesb. No (Impaired Dentition)

11. Are intake and output, skin turgor, and weight vacillat-ing?a. Yes (Imbalanced Fluid Volume, Risk for)b. No (Fluid Balance, Readiness for Enhanced)

12. Is the patient able to move freely in bed? Ambulateseasily?a. Yesb. No (Impaired Tissue Integrity; Impaired Skin

Integrity, Risk for or Actual)13. Review the patient’s temperature measurement. Is the

temperature within normal limits?a. Yesb. No (Ineffective Thermoregulation; Hyperthermia;

Hypothermia)14. Is the patient’s temperature above normal?

a. Yes (Ineffective Thermoregulation; Hyperthermia)b. No

15. Is the patient’s temperature below normal?a. Yes (Ineffective Thermoregulation; Hypothermia)b. No

16. Is the patient exhibiting signs or symptoms of infec-tion? Vasoconstriction? Vasodilation? Dehydration?a. Yes (Imbalanced Body Temperature, Risk for)b. No

17. Ask the patient: “Do you have any problems swallow-ing food? Fluids?”a. Yes (Impaired Swallowing; Risk for Aspiration)b. No

18. Does the patient report chronic health problems?a. Yes (Adult Failure to Thrive)b. No

19. Does the patient complain of being nauseated?a. Yes (Nausea)b. No

● N O T E : The next questions pertain only to a motherwho is breastfeeding.

120 Nutritional–Metabolic Pattern

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20. Weigh the infant. Is his or her weight within normallimits for his or her age?a. Yes (Effective Breastfeeding)b. No (Ineffective Breastfeeding)

21. Ask the patient: “Do you have any problems or con-cerns about breastfeeding?”a. Yes (Ineffective Breastfeeding)b. No (Effective Breastfeeding)

CONCEPTUAL INFORMATION

The nutritional–metabolic pattern requires looking at fourseparate but closely aligned aspects: nutrition, fluid balance,tissue integrity, and thermoregulation. All four functionallyinterrelate to maintain the integrity of the overall nutri-tional–metabolic functioning of the body.

Food and fluid intake provides carbohydrates, pro-teins, fats, vitamins, and minerals, which are metabolized bythe body to meet energy needs, maintain intracellular andextracellular fluid balances, prevent deficiency syndromes,and act as catalysts for the body’s biochemical reactions.1

NUTRITION

Nutrition refers to the intake, assimilation, and use of foodfor energy, maintenance, and growth of the body.2 Assistingthe patient in maintaining a good nutritional–metabolic sta-tus facilitates health promotion and illness prevention, andprovides dietary support in illness.1

Swallowing is associated with the intake of food or flu-ids. Swallowing is a complex activity that integrates sensory,muscular, and neurologic functions that generally occur infour phases: (1) oral preparatory phase, during which thefood is chewed, mixed with saliva, and prepared for diges-tion; (2) oral phase, during which food is moved backwardpast the hard palate and downward to the pharynx; (3) pha-ryngeal phase, when the larynx closes and the food entersthe esophagus; and (4) esophageal phase, during which thefood passes through the esophagus, in peristaltic movement,to the stomach. The first two phases are voluntarily con-trolled, and the last two phases are involuntarily controlled.

Many factors affect a person’s nutritional status, suchas food availability and food cost; the meaning food has foran individual; cultural, social, and religious mores; andphysiologic states that might alter a person’s ability to eat.3

In essence, we are initially concerned with the adequacy orinadequacy of the patient’s nutritional state. If the diet isadequate, there is no major reason for concern, but we mustbe sure that all are defining “adequacy” in a similar manner.Most people are likely to define an adequate diet as one thatprevents hunger; however, professionals look at an adequatediet as being one in which nutrient intake balances withbody needs.

The familiar Food Pyramid was recently revised toreflect an evolving philosophy/outlook regarding the state ofnutrition in the U.S. Dietary Guidelines. The guidelines

moved away from using servings as the benchmark for nutri-ent intake to daily amounts expressed in cups or ounces. Thecurrent recommendations (based on a 2000-calorie diet)include a daily intake of:

• 6 ounces of grains, at least half of which should bewhole grains

• 21/2 cups of vegetables• 2 cups of fruits• 3 cups of milk (or dairy products)*• 51/2 ounces of lean meats and beans

The recommendation to limit fats and oils hasremained unchanged. The new guidelines also encouragemore individualization of diet plans. Individuals can tailortheir diet according to age, activity, and body mass index.More information can be obtained at http://www.mypyra-mid.gov.

● N O T E : Many adults may be lactose intolerant. Lactaseenzymes are now available over-the-counter as a digestiveaid for lactose intolerance.*

An inadequate nutritional state may be reflective ofintake (calories), use of the intake (metabolism), or a changein activity level. Underweight and overweight are the mostcommonly seen conditions that reflect alteration in nutrition.4

Underweight can be caused by inadequate intakeof calories. In some instances, the intake is within RDA,but there is malabsorption of the intake. The malabsorp-tion or inadequate intake can be due to physiologic causes(pathophysiology), psychological causes (anorexia orbulimia), or cultural factors (lack of resources or religiousproscriptions).4

Special notice needs to be given to maternal nutri-tional needs during the postpartum period. New mothersneed optimal nutrition to promote healing of the tissues trau-matized during labor and delivery, to restore balance in fluidand electrolytes created by all the rapid changes in the body,and, if the mother is breastfeeding, to produce adequateamounts of milk containing fluid and nutrients for theinfant.5 Infants have very little room for fluctuation in fluidbalance, especially in the immediate postpartum period.Some researchers believe the infant is behind on fluid intakeimmediately after birth due to inadequate maternal hydra-tion during labor and birth. Human milk has large amountsof fat content to provide the infant with the adequate amountof calories for growth, digestion, physical activity, andmaintenance of organ metabolic function.5 Breastfeedingdemands energy and the mother will experience a gradualweight loss while breastfeeding, as fat deposits stored dur-ing pregnancy are used. However, mothers should not dietduring breastfeeding, as fat-soluble environmental contami-nants to which she has been exposed are stored in her body’sfat reserves. Quick, large amounts of weight loss will releasethese contaminants into her breastmilk.5

The breastfeeding woman can generally meet hernutritional needs and those of her infant through adequatedietary intake of food and fluids; however, because the


••••••


energy demand is greater during lactation, RDA standardsrecommend an additional 200 to 500 extra calories perday be added to the diet to provide adequate nutrients forboth mother and infant, without catabolism of lean tissueof the mother.5

An overweight condition is rarely due to a physiologicdisturbance, although a genetic predisposition may exist.Overweight is most commonly due to an imbalance betweenfood and activity habits (i.e., increased intake and decreasedactivity).4 However, research indicates there is a metabolicset point, and, in actuality, overweight people may be eatingless than normal-weight people.

Either underweight or overweight may be a sign ofmalnutrition (inadequate nutrition), with the result that thepatient exhibits signs and symptoms of less than or morethan body requirements. In either instance, the nurse mustassess the patient carefully for his or her overall conceptof malnutrition.

FLUID VOLUME

Fluid volume incorporates the aspects of actual fluidamount, electrolytes, and metabolic acid-base balance.Regardless of how much or how little a patient’s intake, orhow much or how little a patient’s output, the fluid, elec-trolyte, and metabolic acid-base balances are maintainedwithin a relatively narrow margin. This margin is essentialfor normal functioning in all body systems, and so it mustreceive close attention in providing care.

Approximately 60 percent of an adult’s weight is bodyfluid (liquid plus electrolytes plus minerals plus cells), andapproximately 75 percent of an infant’s weight is bodyfluid. These various parts of body fluid are taken in dailythrough food and drink and are formed through the meta-bolic activities of the body.1,3 The body fluid distributionincludes intracellular (within the cells), interstitial (aroundthe cells), and intravascular (in blood cells) fluids. The com-bination of interstitial and intravascular is known as extra-cellular (outside the cells) fluid. Distribution of body fluidis influenced by both the fluid volume and the concentrationof electrolytes. Body fluid movement, between the compart-ments, is constant and occurs through the mechanisms ofosmosis, diffusion, active transport, and osmotic and hydro-static pressure.1,3

Body fluid balance is regulated by intake (food andfluid), output (kidney, gastrointestinal [GI] tract, skin, andlungs), and hormones (antidiuretic hormones, glucocorti-coids, and aldosterone). The largest amount of fluid islocated in the intracellular compartment, with the volume ofeach compartment being regulated predominantly by thesolute (mainly the electrolytes).

Electrolytes are either positively or negatively chargedparticles (ions). The major positively charged electrolytes(cations) are sodium (the main extracellular electrolyte),potassium (the most common intracellular electrolyte), cal-cium, and magnesium. The major negatively charged elec-

trolytes (anions) are chloride, bicarbonate, and phosphate.The electrolyte compositions of the two extracellular com-partments (interstitial and intravascular) are nearly identical.The intracellular fluid contains the same number of elec-trolytes as the extracellular fluid does, but the intracellularelectrolytes carry opposite electrical charges from the elec-trolytes in the extracellular fluid. This difference betweenextracellular and intracellular electrolytes is necessary forthe electrical activity of nerve and muscle cells.1,3 Therefore,electrolytes help regulate cell functioning as well as the fluidvolume in each compartment.

Usually the body governs intake through thirst andoutput through increasing or decreasing body fluid excretionvia the kidneys, GI tract, and respiration. Because of theway the body governs intake and output, in addition to theeffects of pathophysiologic conditions such as shock, hem-orrhage, diabetes, and vomiting on intake and output, thepatient may enter a state of metabolic acidosis or alkalosis.

Acid–base balance reflects the acidity or alkalinity ofbody fluids and is expressed as the pH. In essence, the pHis a function of the carbonic acid:bicarbonate ratio.3

Acid–base balance is regulated by chemical, biologic, andphysiologic mechanisms. Chemical regulation involvesbuffers in the extracellular fluid, whereas biologic regulationinvolves ion exchange across cell membranes. Physiologicregulation is governed in the lungs by carbon dioxide excre-tion, and in the kidneys through metabolism of bicarbonate,acid, and ammonia.1

Metabolic acidosis is caused by situations in whichthe cellular production of acid is excessive (e.g., diabeticketoacidosis), high doses of drugs (e.g., aspirin) have to bemetabolized, or excretion of the produced acid is impaired(e.g., renal failure).3 Weight reduction practices (fad diets ordiuretics) can contribute to the development of acidosis, ascan chemical substance abuse.1

Fluid volume is affected by regulatory mechanisms,body fluid loss, or increased fluid intake. Because fluid vol-ume is so readily affected by such a variety of factors,continuous assessment for alterations in fluid volume mustbe made.

TISSUE INTEGRITY

Nutrition and fluid are vitally important to tissue mainte-nance and repair. Underlying tissues are protected fromexternal damage by the skin and mucous membranes. Thus,the integrity of the skin is extremely important in the pro-motion of health, because the skin and mucous membranesare the body’s first line of defense. The skin also plays a rolein temperature regulation and in excretion.

The skin and mucous membranes act as protectionthrough their abundant supply of nerve receptors that alertthe body to the external environment (i.e., temperature, pres-sure, or pain). The skin and mucous membranes also act asbarriers to pathogens, thus protecting the internal tissuesfrom these organisms.3


••••••


The skin’s superficial blood vessels and sweat glands(eccrine and apocrine) assist in thermoregulation. As thebody temperature rises, the superficial blood vessels dilateand the sweat glands increase secretion. These two actionsresult in increased perspiration, which, through evaporation,cools the body. During instances of excessive perspiration,water, sodium chloride, and nonprotein nitrogen are excretedthrough the skin; this affects fluid volume and osmotic bal-ance. As the body temperature drops, the opposite reactionsoccur; there is vessel constriction and decreased sweat glandsecretion so that body heat is retained internally.

To fulfill their protective function of the underlyingtissues, the skin and mucous membranes must be intact. Anychange in skin or mucous membrane integrity can allowpathogen invasion, and will also allow fluid and electrolyteloss. Skin and mucous membrane integrity relies on ade-quate nutrition and removal of metabolic wastes (internallyand externally), cleanliness, and proper positioning. In emer-gency surgical settings or in cases of patients in poor health(e.g., very elderly and medically indigent), age and serumalbumin levels might also be predictive of increased risk forskin breakdown.6 Any factor that compromises nutrition,fluid, or electrolyte balance can result in impairment of skinor mucous membrane integrity or, at least, a high risk forimpairment of skin integrity or mucous membrane integrity.

THERMOREGULATION

Thermoregulation refers to the body’s ability to adjust itsinternal core temperature within a narrow range. The coretemperature must remain fairly constant for metabolic activ-ities and cellular metabolism to function for the mainte-nance of life. The core temperature rarely varies as much as2�F. In fact, the range of temperature that is compatible withlife ranges only from approximately 90 to 104�F.

Both the hypothalamus and the thyroid gland areinvolved in thermoregulation. The hypothalamus regulatestemperature by responding to changes in electrolyte bal-ances. Both extracellular cations—sodium and calcium—affect the action potential and depolarization of cells. Whenthere is an imbalance of sodium and calcium within thehypothalamus, hypothermia or hyperthermia can result. Thethyroid glands regulate core body temperature by increasingor decreasing metabolic activities and cellular metabolism,thus altering heat production.

Many factors influence thermoregulation. The skinhas previously been mentioned as a thermoregulatory organ.Heat is gained or lost to the environment by evaporation,conduction, convection, and radiation. Evaporation occurswhen body heat transforms the liquid on a person’s skin tovapor. Conduction is the loss of heat to a colder objectthrough direct contact. When heat is lost to the surroundingcool air, it is called convection. Radiation occurs when heatis given off to the environment, helping to warm it.

A person generally loses approximately 70 percent ofall heat from radiation, convection, and conduction. Another

25 percent is lost through insensible mechanisms of the lungsand evaporation from the skin and about 5 percent is lost inurine and feces. When the body is able to produce and dissi-pate heat within a normal range, the body is in heat balance.7

SUMMARY

The interrelationship of nutrition, fluid balance, thermoreg-ulation, and tissue integrity explains the nursing diagnosesthat have been accepted in the nutritional–metabolic pattern.Indeed, if there is an alteration in any one of these four fac-tors, it would be wise for the nurse to assess the other threefactors to ensure a complete assessment.


INFANT

Swallowing is a reflex present before birth, because duringintrauterine life the fetus swallows amniotic fluid. Followingthe transition to extrauterine life, the infant learns very rap-idly (within 12 to 24 hours) to coordinate sucking and swal-lowing. There are really no developmental considerations ofthe act of swallowing, because it is a reflex.

The normal process for swallowing involves both theepiglottis and the true vocal cords. These two structuresmove together to close off the trachea, and to allow saliva orsolid and liquid foods to pass into the esophagus. The respi-ratory system is thus protected from foreign bodies.

Salivation is adequate at birth to maintain sufficientmoisture in the mouth. However, maturation of many sali-vary glands does not occur until the third month, andcorresponds with the baby’s learning to swallow at otherthan a reflex level.8 Tooth eruption begins at about 6 monthsof age and stimulates saliva flow and chewing. The infanthas a small amount of the enzyme ptyalin, which breaksdown starches.

Water constitutes the greatest proportion of theinfant’s body weight. Approximately 75 to 78 percent ofan infant’s body weight is water, with about 45 percent ofthis water found in the extracellular fluid. The newborninfant loses significant water through insensible methods(approximately 35 to 45 percent) because of the relativelygreater ratio of body surface area to body weight. The respi-ratory rate of an infant is approximately two times that ofthe adult; therefore, the infant is also losing water throughinsensible loss from the lungs. The newborn also loses waterthrough direct excretion in the urine (50 to 60 percent)and through fairly rapid peristalsis as a result of the imma-turity of the GI tract.

The newborn is unable to concentrate urine well, so ismore sensitive to inadequate fluid intake or uncompensatedwater loss.9 The body fluid reserve of the infant is less thanthat of the adult, and because the infant excretes a greatervolume per kilogram of body weight than the adult, infantsare very susceptible to deficient fluid volume. The infant


••••••


needs to consume fluids equal to 10 to 15 percent of bodyweight. Fluid and electrolyte requirements for the newbornare 70 to 100 mL/kg per 24 hours, 2 mEq of sodium andpotassium per kilogram per 24 hours, and 2 to 4 mEq ofchloride per kilogram per 24 hours.

The kidney function of the infant does not reach adultlevels until 6 months to 1 year of age.9 The functional capac-ity of the kidneys is limited, especially during stress. Inaddition, the glomerular filtration rate is low, tubular reab-sorption or secretory capacity is limited, sodium reabsorp-tion is decreased, and the metabolic rate is higher.Therefore, there is a greater amount of metabolic wastes tobe excreted. An infant’s kidney is less able to excrete largeloads of solute-free water than a more mature kidney.10

Feeding behavior is important not only for fluid, butalso for food. The caloric need of the infant for the first 3months is 110 kcal/kg per day, from 3 to 6 months 100kcal/kg per day, and from 6 to 9 months 95 kcal/kg per day.5

Breast milk contains adequate nutrients and vitamins for6 months of life. The American Academy of Pediatrics rec-ommends breastfeeding exclusively for the first 6 months oflife, and continued breastfeeding with inclusion of otherfoods for at least 12 months.5 Some bottle formulas areoverly high in carbohydrates and fat (especially cholesterol),which may lead to an increase in fat cells.

Solid foods should not be introduced until the infant is6 months of age. Studies have indicated that there is a rela-tionship between the early introduction of solid food(younger than 4 months of age) and overfeeding of eithermilk or food, leading to infant and adult obesity.5 The infantshould be made to feel secure, loved, and unhurried at feed-ing time, regardless of whether the mother is breastfeedingor bottle feeding. Skin contact is very important for theinfant for brain development and other physiologic and psy-chological reasons.

The skin of an infant is functionally immature, andthus the baby is more prone to skin disorders. Both the der-mis and the epidermis are loosely connected, and both arerelatively thin, which easily leads to chafing and rub burns.8

Epidermal layers are permeable, resulting in greater fluidloss. Sebaceous glands, which produce sebum, are veryactive in late fetal life and early infancy, causing milia and“cradle cap,” which goes away at about 6 months of age.Dry, intact skin is the greatest deterrent to bacterial invasion.Sweat glands (eccrine or apocrine) are not functional inresponse to heat and emotional stimuli until a few monthsafter birth, and their function remains minimal throughchildhood. The inability of the skin to contract and shiver inresponse to heat loss causes ineffective thermal regulation.4

Also, the infant has no melanocytes to protect against therays of the sun. This is true of dark-skinned infants as wellas light-skinned infants.

The infant’s core body temperature ranges from 97 to100�F. Temperature in the infant fluctuates considerably,because the regulatory mechanisms in the hypothalamus arenot fully developed. (It is not considered abnormal for the

newborn infant to lose 1 to 2�F immediately after birth.) Theinfant is not able to shiver to produce heat, nor does theinfant have much subcutaneous fat to insulate the body.However, the infant does have several protective mecha-nisms by which he or she is able to conserve heat to keep thebody temperature fairly stable. These mechanisms includevasoconstriction so that heat is maintained in the inner bodycore, an increased metabolic rate that increases heat produc-tion, a closed body position (the so-called fetal position) thatreduces the amount of exposed skin, and the metabolism ofadipose tissue. This particular adipose tissue is called“brown fat” because of the rich supply of blood and nerves.Brown fat comprises 2 to 6 percent of body weight of theinfant. Brown fat aids in adaptation of the thermoregulationmechanisms.8 The ability of the body to regulate tempera-ture at the adult level matures at approximately 3 to 6months of age.


By the end of the second year, the child’s salivary glands areadult size and have reached functional maturity.8 The toddleris capable of chewing food, so it stays longer in his or hermouth, and the salivary enzymes have an opportunity tobegin breaking down the food. The saliva also covers theteeth with a protective film that helps prevent decay.Drooling no longer occurs because the toddler easily swal-lows saliva.

Dental caries occur infrequently in children youngerthan 3 years; but rampant tooth decay in very young childrenis almost always related to prolonged bottle feeding at naptime and bedtime (bottle mouth syndrome). The toddlershould be weaned from the bottle, or at least not allowed tofall asleep with the bottle in her or his mouth.11 Parentsshould be taught that the adverse effects of bedtime feedingare greater than thumb sucking or the use of pacifiers.

Affected teeth remain susceptible to decay after nurs-ing stops. If deciduous teeth decay and disintegrate early,spacing of the permanent teeth is affected, and immaturespeech patterns develop. Discomfort is felt and emotionalproblems may result.11

The first dental examination should occur between theages of 18 and 24 months. Dental hygiene should be startedwhen the first tooth erupts by cleansing the teeth with gauzeor cotton moistened with hydrogen peroxide and flavoredwith a few drops of mouthwash. After 18 months, the child’steeth may be brushed with a soft or medium toothbrush.11

Fluoride supplements are believed to prevent cavities.In the toddler, the transition to the appropriate propor-

tion of body water to body weight (62 percent water)begins.12 The extracellular fluid is about 26 percent, whereasthe adult has about 19 percent extracellular fluid. Toddlershave less reserve of body fluid than adults and lose morebody water daily, both from sensible and insensible loss.This age group is highly predisposed to fluid imbalances.13

These imbalances relate to the fact that the kidney still is


••••••


immature, so water conservation is poor, and the toddler stillhas an increased metabolic rate and therefore greater insen-sible water loss than the adult. However, GI motility slows,so this age group is better able to tolerate fluid loss throughdiarrhea. The 2- to 3-year-old needs 1100 to 1200 mL (fourto five 8-ounce glasses) of fluid every 24 hours, whereas thepreschooler needs 1300 to 1400 mL of fluids every 24 hours.

The caloric need in the toddler is 1000 calories/day or100 calories/kg at 1 year and 1300 to 1500 calories/day at 3years. A child should not be forced to “clean the plate” atmealtime, and food should not be viewed as a reward orpunishment. Instead, caloric intake should be related to thegrowing body and energy expenditures.

The caloric need of the preschooler is 85 calories/kg.Eating assumes increasing social significance, and continuesto be an emotional, as well as a physiologic, experience.4

Frustrating or unsettled mealtimes can influence caloricintake, as can manipulative behavior on the part of the childor parent. The child may also be eating foods with emptycalories between meals.

In the toddler, functional maturity of skin createsa more effective barrier against fluid loss; the skin is notas soft as the infant’s, and there is more protection againstoutside bacterial invasion. The skin remains dry becausesebum secretion is limited. Eccrine sweat gland functionremains limited, eczema improves, and the frequency ofrashes declines.

Skin, as a perceptual organ, experiences significantdevelopment during this period. Children like to “feel” dif-ferent objects and textures and like to be hugged. Melanin isformed during these years, and thus the toddler, preschooler,and school-age child are more protected against sun rays.8 Inaddition, small capillaries in the periphery become morecapable of constriction and thus thermoregulation. Also, thechild is able to sense and interpret that he or she is hot orcold, and can voluntarily do something about it.

SCHOOL-AGE CHILD

At this age, the child begins losing baby teeth as permanentteeth erupt. The child should not be evaluated for bracesuntil after all 6-year molars have erupted. The permanentteeth are larger than the baby teeth and appear too large forthe small face, causing some embarrassment. Good oralhygiene is important.

For the school-age child, the percentage of total bodywater to total body weight continues to decrease until about12 years of age, when it approaches adult norms.13

Extracellular fluid changes from 22 percent of body weightat 6 years to 17.5 percent at age 12 as a result of the propor-tion of body surface area to mass, increasing muscle massand connective tissue, and increasing percentage of body fat.

Water is needed for excretion of the solute load.Balance is maintained through mature kidneys, leading tomature urine concentration and acidifying capacities. Fluidrequirements can be calculated in terms of height, weight,

surface area, and metabolic activity. The school-age childneeds approximately 1.5 to 3 quarts of fluid a day. In addi-tion, the child needs a slightly positive water balance. Theelectrolyte values are similar to those for the adult except forphosphorus and calcium (because of bone growth).13

The caloric need of the school-age child is greaterthan that of an adult (approximately 80 calories/kg or 1600to 2200 calories/day). The ages of 10 to 12 reflect the peakages of caloric and protein needs of the school-age child (50to 60 calories/kg per day), because of accelerated growth,muscle development, and bone mineralization. “The schoolage child reflects the nutritional experiences of early child-hood and the potential for adulthood.”4

ADOLESCENT

By age 21, all 32 permanent teeth have erupted. The adoles-cent needs frequent dental visits because of cavities, andalso for orthodontic work that may be in progress. There isa growth spurt and sexual development changes. A totalincrease in height of 25 percent and a doubling of weight arenormally attained.14 Muscle mass increases and total bodywater declines with increasing sexual development.15 Theadolescent needs 34 to 45 calories/kg per day and tends tohave eating patterns based on external environmental cuesrather than hunger. Eating becomes more of a social event.There is a high probability of eating disorders such asanorexia and bulimia arising during this age period.

The basal metabolic rate increases, lung sizeincreases, and maximal breathing capacity and forced expi-ratory volume increase, leading to increased insensible lossof fluid through the lungs. Total body water decreases from61 percent at age 12 to 54 percent by age 18 as a result of anincrease in fat cells. Fat cells do not have as much water astissue cells.15 The water intake need of the adolescent isabout 2200 to 2700 mL per 24 hours.

Sebaceous glands become extremely active duringadolescence and increase in size. Eccrine sweat glands arefully developed and are especially responsive to emotionalstimuli (and are more active in males); apocrine sweatglands also begin to secrete in response to emotional stim-uli.16 Stopped-up sebaceous glands lead to acne, and theadolescent’s skin is usually moist.

YOUNG ADULT

The amount of ptyalin in the saliva decreases after 20 yearsof age; otherwise the digestive system remains fully func-tioning. The appearance of “wisdom teeth,” or third molars,occurs at 20 to 21 years. There are normally four thirdmolars, although some individuals may not fully develop allfour. Third molars can create problems for the individual.Eruptions are unpredictable in time and presentation, andmolars may come in sideways or facing any direction. Thiscan force other teeth out of alignment, which makes chew-ing difficult and painful. Often these molars need to beremoved to prevent irreparable damage to proper occlusion


••••••


of the jaws. Even normally erupting third molars may bepainful. The young adult must see a dentist regularly.

Total body water in the young adult is about 50 to 60percent. There is a difference between males and femalesbecause of the difference in the number of fat cells. Mostwater in the young adult is intracellular, with only about 20percent of fluid being extracellular. Growth is essentiallyfinished by this developmental age.

ADULT

Ptyalin has sharply decreased by age 60 as well as otherdigestive enzymes. Total body water is now about 47 to 54.7percent. Diet and activity indirectly influence the amount ofbody water by directly altering the amount of adipose tissue.The basal metabolic rate gradually decreases along with areduced demand for calories. Caloric intake should beadjusted for age and activity level.

Tissues of the integumentary system maintain ahealthy, intact, glowing appearance until age 50 to 55 if theindividual is receiving adequate vitamins, minerals, othernutrients, and fluids and maintains good personal hygiene.Wrinkles do become more noticeable, however, and bodywater (from integumentary tissues) decreases, leading tothinner, drier skin that bruises much more easily. Fatincreases, leading to skin that is not as elastic and will notrecede with weight loss, so bags develop readily under theeyes.8 Also, skin wounds heal more slowly because ofdecreased cell regeneration.

OLDER ADULT

The nutritional status of the older adult is receivingincreased scrutiny by health-care professionals because ofthe impact poor nutrition has on health status and quality oflife.17,18 Since the early 1990s, many states and organiza-tions working with older adults have begun nutritionalscreening to identify those at high risk for poor nutrition.The Nutrition Screening Initiative (NSI) program encour-ages use of a 10-item checklist entitled “DETERMINE” toidentify at-risk elders. The checklist is easily administeredand results in a score ranging from 0 (lowest risk) to 21(highest risk).19 Scores of 4 or more on the checklist usuallyindicate that the older adult should undergo further nutri-tional evaluation. Many older adults experience agingchanges that can affect nutritional status. Older adults alsoexperience risk factors, such as polypharmacy, social isola-tion, low income, altered functional status, loneliness, andchronic and acute diseases, that impact nutritional status.20

Older adults may experience changes in the mouththat can affect nutrition. Tooth decay, tooth loss, degenera-tion of the jaw bone, progressive gum regression, andincreased reabsorption of the dental arch can make chewingand eating a difficult task for the older adult if good dentalhealth has not been maintained.21 Reduced chewing ability,problems associated with poorly fitting dentures, and adecrease in salivation, secondary to disease or medication,

effects compound nutritional problems for older adults.22

Aging causes atrophy of the olfactory organs and withdiminished smell often comes decreased enjoyment of foodsand decreased consumption.23 Research continues to evolveconcerning taste discrimination in older adults. More recentstudies support limited changes in taste associated withaging when healthy, nonmedicated adults are sampled. Theimpact of medications, poor oral hygiene, or cigarette smok-ing may cause older adults to complain of an unpleasanttaste in their mouth called dysgeusia.24

Changes in olfaction and decreased salivation second-ary to disease or medications can influence the taste of food.When compounded by gum disease, poor teeth, or dentures,problems with food intake can occur. The number of olderadults who are edentulous (without teeth) is graduallydeclining and is estimated to be approximately 37 percent ofadults 70 years of age or older.21 Caries, especially occur-ring on the crowns of the tooth, occur in more than 95 per-cent of the elderly population.21 Older adults are especiallyvulnerable to oral carcinomas.25

Total body water of the older adult is about 45 to 50percent. Older adults have problems tolerating extremes oftemperature. Aging results in skin changes such as drynessand wrinkling. Skin assessment for alterations in fluid vol-ume must be carefully interpreted. Skin turgor assessmentshould be done on the abdomen, sternum, or the forehead.Skin turgor is not a reliable indicator of hydration status inolder adults. Assessment should focus on tongue dryness,furrows in the tongue, confusion, dry mucous membranes,“sunken” appearance of the eyes, or difficulty with speech.26

Older adults also have a diminished thirst sensation second-ary to changes in brain osmoreceptors; thus thirst is notreadily triggered in older adults.25 Changes in blood volumeare minimal. Serum protein (albumin) production isdecreased, but globulin is increased.

Aging changes do bring about changes in nephrotictubular function, which affects removal of water, urine con-centration, and dilution. This leads to a decrease in specificgravity and urine osmolarity. There is a decrease in bladdercapacity, often leading to nocturia. With the change in blad-der capacity, older adults may limit fluid in the evenings tooffset nocturia, but limiting fluids may lead to nocturnaldehydration. Sodium and chloride levels remain constant,but potassium decreases.

Many changes occur in the GI tract, such as decreasedenzyme secretion, gastric irritation, decreased nutrient anddrug absorption, decreased hydrochloric acid secretion,decreased peristalsis and elimination, and decreased sphinc-ter muscle tone, making nutrition a primary concern. Olderadults need decreased and nutrient-dense calories. Adequateintake of vitamins and trace elements along with adequateprotein, fat, carbohydrates, bulk, and electrolytes is impor-tant. The decreased intake of milk and fresh fruits, com-monly found in older populations, is a source of concernbecause of the continuing need for calcium, fiber, and vita-min intake.27


••••••


Integumentary changes result in skin that is drier andthinner, and skin lesions or discolorations, and scaliness(keratosis) may appear. Wrinkling occurs in areas com-monly exposed to the sun, such as the face and hands.Fatty layers lost in the trunk, face, and extremities leads tothe appearance of increased joint size throughout the body.The skin becomes less elastic with aging and may losewater to the air in low-humidity situations, leading to skinchapping.

The older adult has difficulty tolerating temperatureextremes. Body temperature may increase because of adecrease in the size, number, and function of the sweatglands. Decreased fat cells and changes in peripheral

blood flow make older adults more sensitive to coolerconditions. Older adults may wear sweaters or additionallayers of clothing when the external temperature feelscomfortable or warm to younger individuals. Melanocytedecreases lead to pale skin color and gray hair. Hairloss is common. Older women, with imbalances in andro-gen–estrogen hormones, may have noticeable increases infacial and chin hairs. Aging changes to the skin can resultin tactile changes, and therefore, the ability to perceivetemperature, touch, pain, and pressure is diminished.23

Decreased tactile ability may lead to thermal, chemical,and mechanical injury that is not readily detected by theolder adult.


••••••

T A B L E 3 . 1 NANDA, NIC, and NOC Taxonomy Linkages

GORDON’S FUNCTIONAL NANDA NURSING NIC PRIORITYHEALTH PATTERN DIAGNOSIS INTERVENTIONS NOC EVALUATIONS

Nutritional–Metabolic Pattern

Failure to Thrive, Adult

Aspiration, Risk for

Body Temperature, Riskfor Imbalanced

Hope InstillationMood ManagementSelf-Care Assistance

Aspiration PrecautionsTeaching: Infant SafetyVomiting Management

Temperature Regulation:Intraoperative

Vital Signs Monitoring

AppetiteCognitionEnduranceNutritional StatusNutritional Status: Food & Fluid IntakePhysical AgingSelf-Care: ADLWeight: Body MassWill to Live

Aspiration PreventionBody Positioning: Self-InitiatedCognitionCognitive OrientationImmobility Consequences:

PhysiologicalKnowledge: Treatment Procedure(s)Mechanical Ventilation Response:

AdultNausea & Vomiting SeverityNeurological StatusPost Procedure Recovery StatusRespiratory Status: Airway Patency;

VentilationRisk ControlRisk DetectionSeizure ControlSelf-Care: Non-Parenteral MedicationSwallowing Status

HydrationImmune StatusInfection SeverityInfection Severity: NewbornMedication ResponseNeglect Recovery




••••••

T A B L E 3 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 127)


Breastfeeding, Effective

Breastfeeding, Ineffective

Breastfeeding, Interrupted

Dentition, Impaired

Fluid Balance, Readinessfor Enhanced

Fluid Volume, Deficient,Risk for and Actual

Lactation Counseling

Breastfeeding AssistanceLactation Counseling

Bottle FeedingEmotional SupportLactation Counseling

Oral Health MaintenanceOral Health Restoration

*Still in development

Electrolyte MonitoringFluid ManagementFluid MonitoringHypovolumia

ManagementIntravenous IV TherapyShock Management:

Volume

Neurological Status: AutonomicRisk ControlRisk DetectionThermoregulationThermoregulation: Newborn

Breastfeeding Establishment: Infant;Maternal

Breastfeeding MaintenanceBreastfeeding Weaning

Breastfeeding Establishment: Infant;Maternal

Breastfeeding MaintenanceBreastfeeding WeaningKnowledge: Breastfeeding

Breastfeeding MaintenanceBreastfeeding WeaningKnowledge: BreastfeedingParent-Infant Attachment

Oral HygieneSelf-Care: Oral Hygiene

Fluid BalanceFluid Overload SeverityHydrationKidney Function

ActualElectrolyte & Acid/Base BalanceFluid BalanceHydrationNutritional status: Fluid and Food

Intake

Risk forAppetiteBlood Loss SeverityBowel EliminationBreastfeeding MaintenanceElectrolyte & Acid/Base BalanceFluid BalanceHydrationKnowledge: Disease Process; Health

Behaviors; Medication; TreatmentRegimen

Nausea & Vomiting SeverityFood IntakeRisk ControlRisk DetectionSelf-Care StatusSwallowing Status ThermoregulationThermoregulation: NeonateUrinary Elimination



••••••


Fluid Volume, Excess

Fluid Volume, Riskfor Imbalanced

Hyperthermia

Hypothermia

Infant FeedingPattern, Ineffective

Nausea

Electrolyte MonitoringFluid ManagementFluid MonitoringHypervolemia

Management

Electrolyte MonitoringFluid ManagementFluid MonitoringIV Therapy

Fever TreatmentMalignant Hyperthermia

PrecautionsTemperature RegulationVital Signs Monitoring

Hypothermia TreatmentTemperature RegulationTemperature Regulation:

IntraoperativeVital Signs Monitoring

Enteral Tube FeedingLactation CounselingNonnutritive SuckingTube Care: Umbilical Line

Medication ManagementNausea Management

Electrolyte & Acid–Base BalanceFluid BalanceFluid Overload SeverityKidney Function

AppetiteBlood Loss SeverityBowel EliminationBreastfeeding Establishment: InfantBreastfeeding MaintenanceCardiac Pump EffectivenessElectrolyte & Acid–Base BalanceFluid BalanceFluid Overload SeverityHydrationKidney FunctionKnowledge: Disease Process; Health

Behavior; Medication; Treatment RegimenNausea & Vomiting SeverityNutritional status: Food & Fluid IntakePhysical AgingPost Procedure Recovery StatusRisk ControlRisk DetectionThermoregulationThermoregulation: NewbornUrinary EliminationVital SignsWound Healing: Secondary Intention

ThermoregulationThermoregulation: NewbornVital Signs

ThermoregulationThermoregulation: NewbornVital Signs

Aspiration PreventionBreastfeeding Establishment: InfantBreastfeeding: MaintenanceHydrationNutritional Status: Food & Fluid IntakeSwallowing status

AppetiteComfort levelHydrationNausea & Vomiting ControlNausea & Vomiting: Disruptive EffectsNausea & Vomiting SeverityNutritional Status: Food & Fluid Intake




••••••



Nutrition: Readinessfor Enhanced

Nutrition: Imbalanced,Less than BodyRequirements

Nutrition: Imbalanced,More than BodyRequirements, Riskfor and Actual

Swallowing, Impaired

Thermoregulation,Ineffective

Tissue IntegrityImpaired

A. Skin Integrity,Impaired Risk forand Actual

*Currently indevelopment

Eating DisordersManagement

Nutrition ManagementWeight Gain Assistance

Eating DisordersManagement

Nutrition ManagementWeight Reduction

Assistance

Aspiration PrecautionsSwallowing Therapy

Temperature RegulationTemperature Regulation:

Intraoperative

Wound Care

ActualIncision Site CarePressure Ulcer CareSkin SurveillanceWound Care

Knowledge: DietNutritional StatusNutritional Status: Food & Fluid IntakeNutritional Status: Nutrient Intake

AppetiteBreastfeeding Establishment: InfantNutritional StatusNutritional Status: Food & Fluid Intake;

Nutrient IntakeSelf-Care: EatingWeight: Body Mass

ActualNutritional StatusNutritional Status: Food & Fluid Intake;

Nutrient IntakeWeight: Body MassWeight Control

Risk forKnowledge: DietNutritional StatusNutritional Status: Food & Fluid Intake;

Nutrient IntakeRisk ControlRisk DetectionStress LevelWeight: Body MassWeight Control

Aspiration PreventionSwallowing StatusSwallowing Status: Esophageal Phase,

Oral Phase, Pharyngeal Phase

ThermoregulationThermoregulation: Newborn

Tissue Integrity, ImpairedAllergic Response: LocalizedOstomy Self-CareTissue Integrity: Skin & Mucous

MembranesWound Healing: Primary Intention;

Secondary Intention

ActualAllergic Response: LocalizedHemodialysis AccessTissue Integrity: Skin & Mucous

MembranesWound Healing: Primary Intention;

Secondary Intention


Adult Failure to Thrive 131

••••••


B. Oral MucousMembrane, Impaired

Risk forPressure ManagementPressure Ulcer

PreventionSkin Surveillance

Oral health restoration

Risk forAllergic Response: LocalizedChild Development: AdolescenceFluid Overload SeverityHemodialysis AccessImmobility Consequences:

PhysiologicalInfection SeverityInfection Severity: NewbornNutritional StatusNutritional Status: Biochemical

Measures

Ostomy Self-CarePhysical AgingRisk ControlRisk DetectionSelf-Mutilation RestraintTissue Integrity: Skin & Mucous

MembranesTissue Perfusion: PeripheralWound Healing: Primary Intention;

Secondary IntentionOral HygieneTissue Integrity: Skin & Mucous

Membrane


ADULT FAILURE TO THRIVE

DEFINITION28

A progressive functional deterioration of a physical and cog-nitive nature; the individual’s ability to live with multisys-tem diseases, cope with ensuing problems, and manage hisor her care is remarkably diminished.30


1. Anorexia—does not eat meals when offered2. States does not have an appetite, not hungry, or “I don’t

want to eat”3. Inadequate nutritional intake—eating less than body

requirements4. Consumes minimal to no food at most meals (i.e., con-

sumes less than 75 percent of normal requirements ateach or most meals)

5. Weight loss (decreased body mass from baselineweight—5 percent unintentional weight loss in 1 month,10 percent unintentional weight loss in 6 months)

6. Physical decline (decline in body function)7. Evidence of fatigue, dehydration, and incontinence of

bowel and bladder8. Frequent exacerbations of chronic health problems

such as pneumonia or urinary tract infections9. Cognitive decline (decline in mental processing) as

evidenced by problems with responding appropriatelyto environmental stimuli, demonstrates difficulty inreasoning, decision making, judgment, memory, andconcentration, and decreased perception

10. Decreased social skills or social withdrawal—notice-able decrease from usual past behavior in attempts toform or participate in cooperative and independentrelationships (e.g., decreased verbal communicationwith staff, family, and friends)

11. Decreased participation in activities of daily living thatthe older person once enjoyed



••••••


Adult Health

● N O T E : A study29 demonstrated a relationship between Adult Failure to Thrive andHelicobacter pylori infection. The clinical presentation of the infection was character-ized by the lack of symptoms typically associated with gastric diseases, such as nausea,vomiting, dyspepsia, and abdominal pain. Instead, the patient exhibited signs of aversionto food, decline in mental functions, and the inability to perform activities of daily living(ADLs).


Refer to Nutrition, Imbalanced, Less Than Body Require-ments for basic nursing actions or interventions.

Administer nutritional liquids via gastric enteral tube asordered. (See Additional Information for ImbalancedNutrition, Less Than Body Requirements.)

Monitor for:• Swallowing deficit• Occult blood in stools• Dehydration; replace with IV fluids as ordered.• Electrolytes• Document intake and output.

Offer soft, regular diet with nutritional liquid supplement.

Basic methods and procedures that improve nutrition andappetite.

Allows early detection of complications and assists inmonitoring effectiveness of therapy.

Easily chewed and digested food.

12. Self-care deficit—no longer looks after, or takes chargeof, physical cleanliness or appearance

13. Difficulty performing simple self-care tasks14. Neglects home environment and/or financial responsi-

bilities15. Apathy as evidenced by lack of observable feeling or

emotion in terms of normal activities of daily livingand environment

16. Altered mood state—expresses feelings of sadness orbeing low in spirit

17. Expresses loss of interest in pleasurable outlets suchas food, sex, work, friends, family, hobbies, or enter-tainment

18. Verbalizes desire for death

RELATED FACTORS28

1. Depression2. Apathy3. Fatigue


1. Any terminal diagnosis (e.g., cancer, AIDS, or multiplesclerosis)

2. Chronic clinical depression3. Any chronic disease4. Cerebrovascular accident or paralytic conditions


Imbalanced Nutrition, LessThan Body RequirementsThis diagnosis could be a companion diagnosisbecause Imbalanced Nutrition, Less Than BodyRequirements would be a defining characteristic inAdult Failure to Thrive. Adult Failure to Thrive appearsin chronic conditions, and involves much more thanjust altered nutrition.

Impaired SwallowingThis diagnosis relates only to the swallowing processand is not inclusive enough to cover all the problemareas of Adult Failure to Thrive.

EXPECTED OUTCOME

Will gain [number] pounds of weight by [date].Makes [number] of decisions related to care by [date].

TARGET DATES

Adult Failure to Thrive will require long-term intervention.Target dates should initially be stated in terms of weeks.After improvement is shown, target dates can be expressedin terms of months.


Adult Failure to Thrive 133

••••••

Child Health

This diagnosis would not be used with infants or children.

Women’s Health

Nursing actions for this diagnosis are the same as those for Adult Health, Mental Health, and Gerontic Health.

Mental Health

● N O T E : For clients with severe or life-threatening compromised physiologic status,refer to Adult Health for interventions. When the client is psychologically unstable, referto the following plan of care. The adult and psychiatric interventions can be combinedbased on client need. Monitor client for suicidal ideation. If this is determined to be anissue, appropriate interventions should be implemented utilizing the Risk for Suicidediagnosis. Also utilize plans for Ineffective Individual Coping and Disturbed ThoughtProcess as appropriate.




Schedule periods of rest and activity.Develop contract with patient to assume increasing

responsibility ADLs. [Note patient’s contract here.]Do not force feed.

Collaborate with:

• Psychiatric nurse clinician• Nutritionist/dietician

• Physical/occupational therapist

Risk for aspiration pneumonia.

Provides basic resources and information needed; pro-motes holistic approach to treatment.

To address underlying emotional and cognitive problems.Formulate appropriate nutrient intake to support health

restoration.To preserve and improve physical abilities to assume

responsibility of ADLs.

Spend [number of] minutes with the client [number of]times per shift to establish relationship with the client.

Discuss with the client and client’s support system theclient’s food/fluid preferences. [Note here special foodsand adaptations needed.]

Provide the client with opportunity to make food/fluidchoices. Initially these should be limited so the clientwill not be overwhelmed with decisions. [Note clientchoices here.]

Provide the client with necessary sensory and eating aids.[Note here those needed for this client. This couldinclude eyeglasses, dentures, and special utensils.]

Provide quiet, calm milieu at mealtimes.

Provide the client with adequate time to eat.

Opportunities to increase personal control improve self-esteem and have a positive impact on mood.30–32

Clients with mood disorders may have difficulty withconcentration.33

Clients with mood disorders may experience psychomo-tor retardation that can expand the time it takes themto eat.33



••••••

Gerontic Health


Review the older adult’s medication list for possiblemedication-induced failure to thrive.

Monitor weight loss pattern according to care setting pol-icy or client contact opportunities. Maintain weightinformation in an easily retrievable place to allowquick access and ease in comparison of weights.

Review nutritional pattern with the client and/or care-giver to determine whether adequate nutritional sup-port is present.

Arrange for psychological supports for the older client,such as validation therapy, reminiscing, life review,or cognitive therapy.

Refer the older client for evaluation of depression.

Review the social support system available to the client.

Encourage the client to participate in a regular programof exercise.

Adverse reactions to medications such as antidepressants,beta-blockers, neuroleptics, anticholinergics, benzodi-azepines, potent diuretic combination drugs, and anti-convulsants and polypharmacy (more than four to sixprescription drugs) can lead to cognition changes,anorexia, dehydration, or electrolyte problems andresult in failure to thrive.34

In older adults, a percentage weight loss over a 6- to12-month time period is associated with increased riskof disease, disability, and mortality.35

Poor nutrition can lead to adverse clinical outcomes forolder adults.35

The therapies listed promote self-worth, decreasestress, focus on the client’s strengths, and providethe opportunity for resolution of prior unfinishedconflicts.36

Depression is frequently underdiagnosed in the olderadult and is often associated with unintentional weightloss in the older population.35

Social isolation is considered a significant feature indepression, malnutrition, and decreased function inolder adults.37

Exercise can prevent further loss of muscle mass oftenfound with failure to thrive and improve strength andenergy.25


Mental Health


Provide foods that meet the client’s preferences, are ofhigh nutritional value, and require little energy to eat.[Note client’s preferences here.]

Sit with the client during meals and provide positive ver-bal reinforcement. [Note here client-specific rein-forcers.]

When the client’s mental status improves, spend [numberof] minutes each shift with the client discussing issuesand concerns. [Note here those issues important for theclient to discuss.]

Provide prescribed medications and monitor for effects.

When the client’s mental status improves, engage theclient in [number of] therapeutic groups per day. [Notehere the groups the client will attend.]

Meeting basic health needs improves stamina.33

Fatigue may limit the client’s physical energy.33

This demonstrates acceptance of the client and facilitatesproblem solving.31

Decreases sense of loneliness and isolation, increases self-understanding, increases social support, and facilitatesthe development of relationship and coping skills.31,32


Aspiration, Risk For 135

••••••

Home Health/Community Health


Monitor the client’s ability to provide basic self-care;provide referrals for community agencies to augmentdeficits in self-care. Many agencies offer assistancewith personal hygiene, transportation, meal prepara-tion, and light housework in the home.

Provide with information and resources to facilitatethe client keeping a food diary to track intake.Monitor the adequacy of the diet in terms ofcalories and nutrients. Secure a dietary consultas appropriate.

Weigh the client on each home visit.

Facilitate the delivery of meals for home bound clients.Refer the client to services available in his or herarea. [Note support needed from nursing here to sus-tain this support.]

Refer the client to age- and condition-specific communityexercise programs available in his or her area. Develop,with the client, a reward system that would reinforcehis or her involvement in the program. [Note theclient’s plan here.]

Spend [number] minutes each visit talking with the clientand family about their social support system. Makereferrals as needed to community agencies that provideneeded services. Many agencies provide services suchas counseling and volunteer visitors. [Note the supportneeded from nursing to facilitate and sustain theseinteractions.]

Difficulty in performing self-care and ADLs are definingcharacteristics of Adult Failure to Thrive.

Poor nutrition can lead to adverse clinical outcomes.

Weight loss is a defining characteristic of AdultFailure to Thrive. Significant weight loss may leadto increased risk of disease and exacerbation of thecondition.

Increases the availability of well rounded, nutrient-densemeals.

Physical decline is a defining characteristic of AdultFailure to Thrive.

Social isolation is a defining characteristic of AdultFailure to Thrive.

ASPIRATION, RISK FOR

DEFINITION28

The state in which an individual is at risk for entry of GIsecretions, oropharyngeal secretions, or solids or fluids intotracheobronchial passages.28


1. Increased intragastric pressure2. Tube feedings3. Situations hindering elevation of upper body4. Reduced level of consciousness5. Presence of tracheostomy or endotracheal tube6. Medication administration7. Wired jaws8. Increased gastric residual9. Incompetent lower esophageal sphincter

10. Impaired swallowing11. GI tubes12. Facial, oral, or neck surgery or trauma13. Depressed cough and gag reflexes14. Decreased GI motility15. Delayed gastric emptying

RELATED FACTORS28

The risk factors also serve as the related factors for this nurs-ing diagnosis.


1. Closed head injury2. Any diagnosis with presenting symptoms of nausea and

vomiting3. Bulimia4. Any diagnosis requiring use of a nasogastric tube5. Spinal cord injury



••••••


Adult Health


Considerations for the naso/orogastric intubated patients:

Confirm placement at least once every shift when thepatient is receiving continuous feeds, prior to bolusfeeds, or prior to medication administration.

Monitor residual of feeding tube at least once every shiftwhen the patient is receiving continuous feeds andprior to bolus feeds.

Considerations for endotrach intubation:• Maintain head of bed 30 to 45 degrees unless con-

traindicated.• Provide mouth care at least every four hours. [Note

times here.]• Ensure that balloon cuff is appropriately inflated.

• Extubate at the earliest opportunity.

• Suction above and below the balloon cuff prior to extu-bation.

Considerations for the patient with noninvasive positivepressure ventilation (e.g., bi-PAP).

• Implement gastric decompression via naso/orogastricintubation.

• Devise alternative oxygenation strategies during oralintake.

To assure correct placement of feeding tubes.

Monitors patient tolerance of tube feeding regimen.

Secretions in the oropharyngeal cavity are a source ofmicroaspiration.

Underinflated balloon cuffs allow passage of oral secre-tions into the trachea.

Extubation will allow the normal capacities of swallow-ing with which endotracheal intubation interferes.

To eliminate oral secretions that can be aspirated.

Gastric distention can occur with positive pressure masks,increasing the potential for aspiration.

Food and fluids become projectiles under the influence ofpositive pressure masks.


Impaired SwallowingSwallowing means that when food or fluids are presentin the mouth, the brain signals both the epiglottis andthe true vocal cords to move together to close off thetrachea so that the food and fluids can pass into theesophagus and thus into the stomach. ImpairedSwallowing implies that there is a mechanical or physi-ologic obstruction between the oropharynx and theesophagus that prevents food or fluids from passinginto the esophagus. In Risk for Aspiration there may ormay not be an obstruction between the oropharynxand the esophagus. The major pathophysiologic dys-function that occurs in Risk for Aspiration is the inabil-ity of the epiglottis and true vocal cords to move toclose off the trachea. This inability to close off the tra-chea may occur because of pathophysiologic changesin the structures themselves, or because messages tothe brain are absent, decreased, or impaired.

Ineffective Airway ClearanceIn Ineffective Airway Clearance, the patient is unableto effectively clear secretions from the respiratory

tract because of some of the same related factors asare found with Risk for Aspiration. However, inIneffective Airway Clearance, the defining characteris-tics (abnormal breath sounds, cough, change in rateor depth of respirations, etc.) are associated directlywith respiratory function, whereas the defining char-acteristics of Risk for Aspiration are directly or indi-rectly related to the oropharyngeal mechanisms thatprotect the tracheobronchial passages from theentrance of foreign substances.

EXPECTED OUTCOME

Will describe [number] of strategies to decrease risk foraspiration by [date].

TARGET DATES

Aspiration is life threatening. Initial target dates shouldbe stated in hours. After the number of risk factors hasbeen reduced, the target dates can be moved to 2- to 4-dayintervals.


Aspiration, Risk For 137

••••••


In preparation for discharge:• Teach the patient to eat when calm and in a relaxed,

nonstimulating atmosphere.• Teach the patient and family the Heimlich maneuver

and have them return-demonstrate at least daily for 3days before discharge.

• Teach the patient and family suctioning technique asneeded, including appropriate ordering of supplies.

Would assist in episodes of choking, and allow the patientand family to feel comfortable with level of expertisebefore going home.

Child Health


Determine best position for the patient as determined byunderlying risk factors (e.g., head of bed elevated 30degrees with the infant propped on right side afterfeeding).

• Confirm need for special positioning with pediatricianor primary health-care provider as this constitutes adeviation from the BACK TO SLEEP protocol to pre-vent risk for SIDS, especially in infants from birth to6 months of age.

Check bilateral breath sounds every 30 minutes or withany change in respiratory status.

Measure amount of residual, immediately before feeding,in nasogastric tube and report any excess beyond 10 to20 percent of volume or as specified.

Note and record the presence of any facial trauma or sur-gery of face, head, or neck with associated drainage.

Monitor for risk factors that would promote aspiration(e.g., increased intracranial pressure, Reye’s syndrome,nausea associated with medications, cerebral palsy, orneurologic damage).

Assist the patient and family to identify factors that helpprevent aspiration (e.g., avoiding self-stimulation ofgag reflex, avoiding deep oral or pharyngeal suction-ing, and chewing food thoroughly).

Provide opportunities for the patient and family to askquestions or ventilate regarding risk for aspiration byscheduling at least 30 minutes twice a day at [times]for discussing concerns.

Teach the family and patient (if old enough) age-appropriate cardiopulmonary resuscitation (CPR),first aid, and Heimlich maneuver.

Natural upper airway patency is facilitated by uprightposition. Turning to right side decreases likelihood ofdrainage into trachea rather than esophagus in theevent of choking.

In the event of aspiration, increased gurgling and raleswith correlated respiratory difficulty (from mild tosevere) will be noted.

Monitors the speed of digestion and indicates thepatient’s ability to tolerate the feeding.

Monitoring for these risk factors assists in preventingunexpected or undetected aspiration.

An increased stimulation or sensitivity to the gag reflexincreases the likelihood of choking and possibleaspiration.

Allows an opportunity to decrease anxiety, provides timefor teaching, and allows individualized home careplanning.

Basic safety measures for dangers of aspiration.




••••••


Women’s Health

● N O T E : The following actions pertain to the newborn infant if meconium is presentin amniotic fluid.


Alert obstetrician and pediatrician of the presence ofmeconium in amniotic fluid.

Assemble equipment and be prepared for resuscitationof the newborn at the time of delivery.

Be prepared to suction the infant’s nasopharynx andoropharynx while head of the infant is still on theperineum.

Immediately evaluate and record the respiratory status ofthe newborn infant.

Assist pediatrician in viewing the vocal cords ofthe infant (have various sizes of pediatric laryn-goscopes available). If meconium is present, beprepared to insert endotracheal tube for furthersuctioning.

Continue to evaluate and record the infant’s respiratorystatus.

Reassure the parents by keeping them informed of actions.

Allow opportunities for the parents to verbalize fears andask questions.

Presence of meconium alerts health-care providers topossible complications.

Basic emergency preparedness.

There is no designated time frame for observation;however, the nurse needs to continue to evaluatethe infant for at least 12 to 24 hours for respiratorydistress and the complications of pulmonary intersti-tial emphysema, pneumomediastinum, pneumotho-rax, persistent pulmonary hypertension, centralnervous system (CNS) dysfunction, and renal failure.These infants should be placed in a level 2 or 3nursery.

Reduces anxiety.

Reduces anxiety and provides teaching opportunity.

Mental Health

● N O T E : Clients receiving electroconvulsive therapy (ECT) are at risk for thisdiagnosis.


Remain with the client who has had ECT until gag reflexand swallowing have returned to normal. Monitor gagreflex and swallowing every [number] minutes untilreturn to normal.

Place the client who has had ECT on right side untilreactive.

Clients in four-point restraint should be placed on right sideor stomach. Elevate the client’s head to eat, and removerestraints one at a time to facilitate eating. Request thatoral medications be changed to liquid forms.

Observe clients receiving antipsychotic agents for possi-ble suppression of cough reflex.

Basic safety measures until the client can demonstratecontrol.

Lessens the probability of aspiration through the influ-ence of gravity on stomach contents.

Lessens probability of aspiration due to difficulty in swal-lowing tablets or pills that might cause gagging.

One side effect of these medications is suppression of thecough reflex. Loss of this reflex promotes the likeli-hood of aspiration.38


Body Temperature, Imbalanced, Risk For 139

••••••

Gerontic Health


Older adults may develop a decreased gag reflex. Toreduce the risk of aspiration:

• Monitor gag reflex before any procedures involv-ing anesthesia such as bronchoscopy, esophagogas-troduodenoscopy (EGD), or general surgery.

Monitor gag reflex post procedure before giving fluidsor solids.

Establishes baseline data to use for comparison after theprocedure is completed.

Ensuring return of gag reflex decreases risk of aspirationonce oral intake is resumed.



Secure proper equipment for patient’s home to preventaspiration, including a bed with adjustable head andsuction machine. Ensure that caregivers are thoroughlyfamiliar with equipment and its proper use.

Teach caregivers and patient how to thicken drinks to theproper consistency as ordered.

Teach patient and caregivers about the importance ofmaintaining head elevation during and after enteralfeedings.

Assess the caregiver’s ability to provide CPR andHeimlich maneuver. Provide re-teaching as needed toensure competence.

Educate caregivers of signs that patient has aspirated.

Educate caregivers of patient symptoms of complicationsof aspiration that indicate the need to seek immediatemedical attention.

Proper supplies are required in the home for preventionof aspiration and emergency relief of aspiration.

Ensures patient safety and family comfort in the homesetting.


Ensures patient safety and family comfort in the homesetting.

To allow early detection and facilitate appropriate care-giver response.

To allow early detection and facilitate appropriate care-giver response.

7. Extremes of age8. Dehydration9. Sedation

10. Exposure to cold or cool or warm or hot environments

RELATED FACTORS28

The risk factors also serve as the related factors for this nurs-ing diagnosis.


1. Any infectious process2. Hyperthyroidism/hypothyroidism3. Any surgical procedure4. Head injuries

BODY TEMPERATURE, IMBALANCED,RISK FOR

DEFINITION28

The state in which the individual is at risk for failureto maintain body temperature within the normal range.30


1. Altered metabolic rate2. Illness or trauma affecting temperature regulation3. Medications causing vasoconstriction or vasodilation4. Inappropriate clothing for environmental temperature5. Inactivity or vigorous activity6. Extremes of weight



••••••


Adult Health


Monitor for factors contributing to Risk for ImbalancedBody Temperature at least every 2 hours on [odd/even]hour. (Refer to Risk Factors.)

Monitor temperature for at least every 2 hours on[odd/even] hour.

Note pattern of temperature for last 48 hours.

Monitor skin and mucous membrane integrity every 2hours on [odd/even] hour.

Monitor intake and output every hour.

If temperature is above or below parameters defined byhealth-care provider, take appropriate measures tobring temperature back to normal range. Refer to nurs-ing actions for Hypothermia and Hyperthermia.

Collaborate with health-care team in identifying causativeorganisms.

Maintain consistent room temperature.

Teach the patient to wear appropriate clothing and modifyroutines to prevent alterations in body temperature:

• Teach the patient how to manage activity with regard toenvironmental conditions that can influence tempera-ture imbalance (e.g., not engaging in outdoor activitiesin extreme temperatures).

Detects overproduction or underproduction of heat.

Assists in ascertaining any trends. Typical viral–bacterialdifferentiation may be possible to detect on tempera-ture curves.

Can provide early clues for fluid imbalance. Adequatehydration assists in maintaining normal body core tem-perature.

To maintain fluid balance.

Identification of organism allows determination of mostappropriate antibiotic therapy.

Prevents overheating or overcooling due to environment.

Regulates constant metabolism and provides warmth.


Risk for Imbalanced Body TemperatureRisk for imbalanced body temperature needs to bedifferentiated from Hypothermia, Hyperthermia, andIneffective Thermoregulation.

HypothermiaHypothermia is the condition in which a person main-tains a temperature lower than normal for him or her.This means that the body is probably dissipating heatnormally but is unable to produce heat normally. InRisk for Imbalanced Body Temperature both heat pro-duction and heat dissipation are potentially nonfunc-tional. In Hypothermia, a lower than normal bodytemperature can be measured. In Risk for ImbalancedBody Temperature, temperature measurement maynot show an abnormality until the condition haschanged to Hyperthermia or Hypothermia.

HyperthermiaHyperthermia is the condition in which a person main-tains a temperature higher than normal. This meansthat the body is probably producing heat normally but

is unable to dissipate the heat normally. Both heatproduction and heat dissipation are potentially non-functional in Risk for Imbalanced Body Temperature.As with Hypothermia, a temperature measurementshows an abnormal measurement.

Ineffective ThermoregulationIneffective Thermoregulation means that a person’stemperature fluctuates between being too high andtoo low. There is nothing wrong, generally, with heatproduction or heat dissipation; however, the ther-moregulatory systems in the hypothalamus or the thy-roid are dysfunctional. Again, a temperaturemeasurement shows an abnormality.

EXPECTED OUTCOME

Will have no alteration in body temperature by [date].

TARGET DATES

Initial target dates would be stated in hours. After stabiliza-tion, target dates could be extended to 2 to 3 days.



••••••

Child Health


Monitor temperature at least every hour.

If temperature is less than 97�F rectally (or parametersdefined by physician), take appropriate measures formaintaining temperature:

• Infants: Radiant warmer or isolette

• Older child: Thermoblanket• Administer medications as ordered.

Be cautious to not overdose in a 24-hour period. Abideby recommended dosage schedule every 8 hours orpediatric medication recommendations.

If temperature is above 101�F, take appropriate measuresto bring temperature back to normal range (or at least98 to 100�F):

• Administer Tylenol, antibiotics, or other medications asordered.

• Monitor and document related symptoms with specificregard for potential febrile seizures.

• Monitor for the development of febrile seizures, andcheck for history of febrile seizures.

• If the infant or child has reduced threshold for seizuresduring times of fever, be prepared to treat seizures withanticonvulsants, maintain airway, and provide forsafety from injury.

• Provide appropriate teaching to the child and parentsrelated to hyperthermia and hypothermia (e.g., temper-

The young infant and child may lack mature thermoregu-latory capacity. Temperatures that are either too high(102�F or above) or too low (below 97�F) may bringabout spiraling metabolic disruption of acid–basestatus. Seizures and shock may follow.

Young infants and children may not be able to initiatecompensatory regulation of temperature, especially inpremature and altered CNS/immune conditions. Thesebasic measures must be taken to safeguard a return tothe homeostatic condition.

Best method of warming newborn infant is to place infanton mother’s chest skin to skin and cover both withwarm blanket. Sometimes infants placed under warm-ers or in isolettes can become dehydrated if not moni-tored adequately.

Using caution in dosage calculation and abiding byappropriate guidelines minimize inadvertent overdos-ing and subsequent untoward effects of medication.

Young infants and children may have febrile seizures dueto immature thermoregulatory mechanisms and mustbe appropriately safeguarded against further sequelae.

Anticipatory planning promotes optimal resuscitationefforts.

Self-care empowers and fosters long-term confidence aswell as reduces anxiety.


Avoid sedatives and tranquilizers that depress cerebralfunction and circulation.

Assist the patient to learn to assess biorhythms.

Teach patient to balance physical and sedentary activity.

Refer to nursing diagnoses Hypothermia or Hyperthermiafor interventions related to these situations once thealteration has occurred.

Risk factors for this diagnosis.

Generally, early morning is the period of lowest bodymetabolic activity. Add extra clothes until food andphysical movement stimulate increased cellular metab-olism and circulation. Helps determine peak and troughof temperature variations.

Assists in maintaining consistency in metabolicfunctioning.




••••••


Child Health


ature measurement, wearing of proper clothing, use ofTylenol instead of aspirin, consuming adequateamounts of food and fluid, and use of tepid baths).

• Be cautious and do not overtax the infant or child withcongestive heart failure or pulmonary problems byallowing a temperature elevation to develop.

• Avoid use of aspirin and aspirin products.

• Avoid use of tympanic membranous thermometer ininfants age 6 months or younger.

Increased metabolic demands in the presence of an alreadytaxed cardiopulmonary status can become severe, result-ing in life-threatening conditions if left untreated.

Standards of care per the American Academy of Pediatricsto decrease the potential for Reye’s syndrome.

Studies indicate that tympanic thermometers are inaccu-rate in infants, especially those younger than 3 monthsof age.

Women’s Health


Assist the patient in identifying lifestyle adjustments nec-essary to maintain body temperature within normalrange during various life phases (e.g., perimenopauseor menopause).

Maintain house at a consistent temperature level of 70to 72�F.

Keep bedroom cooler at night and layer blankets orcovers that can be discarded or added as necessary.

Have the patient drink cool fluids (e.g., iced tea or coldsoda).

Have the patient wear clothing that is layered so thatjackets, etc., can be discarded or added as necessary.

In collaboration with physician, assist the patient inunderstanding role of estrogen and the amount ofestrogen replacement necessary during perimenopauseand menopause.

So-called hot flashes related to changes in the body’s coretemperature can be somewhat controlled in women viaestrogen replacement therapy; however, as hormonelevels fluctuate with the aging process, some hotflashes will occur. These can be helped by adjustingthe environment (e.g., room temperature, amount ofclothing, or temperature of fluids consumed).

Individuals have unique, different requirements as to theamount of estrogen necessary to maintain appropriatehormone levels. It is of prime importance that eachpatient can recognize what her body’s needs are andcommunicate this information to the health-careprovider.39

Mental Health


Observe clients receiving neuroleptic drugs for signs andsymptoms of hyperthermia. Teach clients these symp-toms and caution them to decrease their activities inthe warmest part of the day and to maintain adequatehydration, especially if they are receiving lithium car-bonate with these drugs.

Neuroleptic drugs may decrease the ability to sweat, andtherefore make it difficult for the client to reduce bodytemperature.38,40



••••••


Observe clients receiving antipsychotics and antidepres-sants for loss of thermoregulation. Elderly client, espe-cially, should be monitored for this side effect. Providethe client with extra clothing and blankets to maintaincomfort. Protect this client from contact with uncon-trolled hot objects such as space heaters and radiators.Heating pads and electric blankets can be used withsupervision.

Do not provide electric heating devices to the client whois on suicide precautions or who has alterations inthought processes.

Notify physician if the client receiving antipsychoticagents has an elevation in temperature or flu-likesymptoms.

Review the client’s complete blood count (CBC) beforedrug is started, and report any abnormalities on subse-quent CBCs to the physician.

Clients receiving phenothiazines should be monitored forhot, dry skin, CNS depression, and rectal temperatureelevations (can be as high as 108�F). Monitor theclient’s temperature three times a day while awake at[times]. Notify physician of alterations.

Monitor clients receiving tricyclic antidepressants (TCAs)and the monoamine oxidase inhibitors (MAOIs) foralterations in temperature three times a day whileawake. [Note times here.] Notify physician of anyalterations.

Antipsychotics and antidepressants can cause a lossof thermoregulation. The client’s learned avoidancebehavior can be altered and consciousness can beclouded as a result of medications. Hypothermia ismore common that hyperthermia.38,40


Antipsychotics, especially chlorpromazine and thiori-dazine, can cause agranulocytosis. This risk is greatest3 to 8 weeks after therapy has begun.38,40 Clients whohave experienced this side effect in the past should notreceive the drug again because a repeat episode ishighly possible.

Basic monitoring for agranulocytosis.

These medications can produce hyperthermia, which canbe fatal. This hyperthermia is due to a peripheral auto-nomic effect.38,40

The side effect of a hyperpyretic crisis can be producedin clients receiving these medications.38,40

Gerontic Health

● N O T E : Normal changes of aging can contribute to altered thermoregulation. Age-related changes that may be associated with altered thermoregulation are a decrease infebrile response, inefficient vasoconstriction, decreased cardiac output, decreased subcu-taneous tissue, diminished shivering, diminished temperature sensory perception, anddiminished thirst perception. Thus, older clients are at high risk for alterations in ther-moregulation, both hyperthermia and hypothermia.

In addition to the interventions for Adult Health the following can be utilized with the older adult client.


Check on older adults often who are at risk:• During heat alerts• During cold weather• In homes without air conditioning or heating• During electrical outages or electrical service

interruptions

Instruct/assist client to select proper clothing:• Layers during cold weather and lighter garments during

warmer weather

Primary preventive measure.

Primary preventive measure




••••••


Gerontic Health


Monitor and record the temperature of older clients oftenand regularly during high-risk times:

• Intra- and postoperative period• When infection is present• When fluid imbalance is present

Use warmed IV solutions in older clients in the intra-/postoperative period unless hyperthermia is present.

Tracks client norms and provides a mechanism for earlyidentification of changes.

Prevent episodes of hypothermia.



Teach measures to decrease or eliminate Risk forImbalanced Body Temperature:

• Wearing appropriate clothing• Taking appropriate care of underlying disease• Avoiding exposure to extremes of environmental

temperature• Maintaining temperature within norms for age, sex,

and height• Ensuring appropriate use of medications• Ensuring proper hydration• Ensuring appropriate shelter

Assist the client and family to identify lifestyle changesthat may be required:

• Learn safety and thermal injury prevention measuresif client works or plays outdoors.

• Measure temperature in a manner appropriate for thedevelopmental age of the person.

• Maintain ideal weight.• Avoid substance abuse.

Involve the client and family in planning, implementing,and promoting reduction or elimination of the Risk forImbalanced Body Temperature by establishing familyconferences to set mutual goals and to improve com-munication.

Monitor the patient’s need for assistive resources and pro-vide referrals as needed.

Pay particular attention to the client’s ability to pay forheat and cooling in the home. Many communities havefinancial assistance programs for vulnerable personswho cannot afford appropriate heating and cooling.

Appropriate environmental temperature regulation pro-vides support for physiologic thermoregulation.

Support is often helpful when individuals and familiesare considering lifestyle alterations.

Involvement of the client and family provides opportunityto increase motivation and enhance self-care.

Utilization of existing resources can prevent injury orillness.

BREASTFEEDING, EFFECTIVE

DEFINITION28

The state in which a mother–infant dyad–family exhibitsadequate proficiency and satisfaction with the breastfeedingprocess.


1. Mother–infant communication patterns (infant cues,maternal interpretation, and response) are effective.

2. Regular and sustained suckling and swallowing at thebreast.


the baby. If there is a problem with breastfeeding,then the appropriate diagnosis is IneffectiveBreastfeeding. These two diagnoses could beconsidered to be at opposite ends of a continuum.

Impaired ParentingEffective Breastfeeding focuses on the nutrition andgrowth of the infant, rather than on the degree ofattachment with the infant. Although Effective Breast-feeding contributes to the attachment of the infant tothe mother and the mother to the infant, the supplyingof the infant with nutrition by breastfeeding or by for-mula feeding should be differentiated from attachmentprocesses, which are addressed in Impaired Parent-ing, Risk for or Actual, and Parental Role Conflict.

EXPECTED OUTCOME

The infant will have all of the following:

1. Adequate weight gain and return to birth weight by3 weeks of age

2. Six or more wet diapers in 24 hours, after 2 days3. At least two stools every 24 hours, after 2-3 days

TARGET DATES

Although it usually takes 2 to 3 weeks for the mother andinfant to establish a synchronized pattern of feeding, an ini-tial target date of 4 days should be set to ensure an effectivebeginning to the breastfeeding process.

Breastfeeding, Effective 145

••••••

3. Appropriate infant weight patterns for age.4. Infant is content after feeding.5. Mother able to position infant at breast to promote a

successful latch-on response.6. Signs and/or symptoms of oxytocin release (let-down or

milk ejection reflex).7. Adequate infant elimination patterns for age.8. Eagerness of infant to nurse.9. Maternal verbalization of satisfaction with the breast-

feeding process.

RELATED FACTORS28

1. Infant gestational age more than 34 weeks2. Support sources3. Normal infant oral structure4. Maternal confidence5. Basic breastfeeding knowledge6. Normal breast structure


Because this is a wellness diagnosis, there are no relatedclinical concerns.


Effective BreastfeedingEffective Breastfeeding is a wellness diagnosis. It sig-nifies a successful experience for both the mother and


Adult Health

For this diagnosis, Women’s Health nursing actions serve as the generic actions. This diagnosis would probably not ariseon an adult health unit.

Child Health

While the infant and mother typically have established effective breastfeeding within the first week or so of life there areinstances when a need for intervention does occur on the child health-care unit. Obviously the reason for hospitalizationis considered in the plan for effective breastfeeding, especially when surgical intervention is a part of the plan of care. Insuch instances mothers are encouraged to pump during times when the infant is NPO or unable to breastfeed, and freezethe expressed milk in individual bottles labeled for future use. Please see nursing actions under Women’s Health for addi-tional interventions.

Women’s Health

● N O T E : If the diagnosis of Effective Breastfeeding has been made, the most appropri-ate nursing action is continued support for the diagnosis. Successful lactation can beestablished in any woman who does not have structural anomalies of the milk ducts andwho exhibits a desire to breastfeed. Adoptive mothers can breastfeed as well as birth-mothers. The following actions serve to facilitate the development of EffectiveBreastfeeding.




••••••


Women’s Health


Review the mother’s knowledge base regarding breast-feeding prior to the initial breastfeeding of the infant.Information on benefits of breastfeeding must be givento the patient’s extended family as well as the patient.The nutritional merit of breastfeeding must beembraced by the extended family. Social, emotional,and spiritual aspects of breastfeeding must beaddressed. Education must be tailored culturally and toeach community’s beliefs.

The baby is kept with the mother immediately after birthso that breastfeeding can be initiated at the time thenewborn is most receptive (within the first hour afterbirth).

Demonstrate and assist the mother and significant otherwith correct breastfeeding techniques (e.g., positioningand latch-on).

Teach the mother and significant other basic informationrelated to successful breastfeeding (e.g., milk supply,diet, rest, breast care, breast engorgement, infanthunger cues, and parameters of a healthy infant).

Assess the mother’s breasts for graspable nipples, surgi-cal scars, skin integrity, and abnormalities prior to theinitial breastfeeding of the infant.

Assess the infant for ability to breastfeed prior tobreastfeeding (e.g., state of awareness or physicalabnormalities).

Place the infant to breast within the first hour after birth.

To initiate or maintain lactation when the mother isunable to breastfeed the infant, encourage the motherto express breast milk either manually or by using abreast pump at least every 3 hours.

Success or failure to breastfeed is strongly influenced byfamily and community, their values and beliefs. Sisters,aunts, mothers, and grandmothers play a large role inbreastfeeding success. Determining the basis for assis-tance and teaching is essential to avoid nonessentialrepetition and confusion for the mother.41–43

Confidence is gained through knowledge. Research hasshown that providing pregnant women with accuratebreastfeeding information increases breastfeeding initi-ation rates.44

Research has shown that not separating the mother andbaby after birth leads to higher success rates withbreastfeeding.41–49

Successful lactation depends on understanding the basichow-to’s and correct techniques for the actual feedingact. Women who attend prenatal breastfeeding skillseducation and a breastfeeding class before dischargeincreased breastfeeding knowledge. These women hada significantly higher rate of breastfeeding at 6 monthspostpartum.44,49

Informing the family about how they can support andhelp the new mother increases the success rate ofbreastfeeding after return home. Small things such asfixing a cup of tea (hydration for the mother), runninga bath, minding the older siblings, or making a quicktrip to the grocery store, gives the new mother time tobreastfeed.5,41

Provides the assessment base for diagnosing of potentialproblems as well as the base for developing strategiesfor success.

It is important to work with the infant’s sleep–wake cyclein establishing breastfeeding. If the infant can success-fully suckle immediately after birth, a successful andencouraging pattern is usually established for both themother and the infant.

This assists in establishing and maintaining the milksupply. The hospital-grade electric pump with a doublecollecting kit is essential equipment in helping mothersmaintain milk supply when the infant cannot suckle ata breast. This is an important part of the success of thismother to provide nutrition and emotional support aswell as nutritional support to the infant who cannotbreastfeed because of prematurity or illness.50,51

● N O T E : Always use a hospital-grade electric pump with a double collecting kit whenassisting mothers of babies in neonatal units to pump.


Breastfeeding, Effective 147

••••••


Observe the infant at breast, noting behavior, position,latch-on, and sucking technique with the initial breast-feeding and then as necessary. Document these obser-vations in the mother’s and infant’s charts.

Encourage the mother and significant other to identifysupport systems to assist her with meeting her physicaland psychosocial needs at home.

Encourage the mother to drink at least 2000 mL of fluidsa day, or 8 ounces of fluids every hour.

To provide sufficient amounts of calcium, proteins, andcalories, encourage the mother to eat a wide variety offoods from the Food Pyramid.5

Encourage the mother to breastfeed at least every 2 to 3hours to establish milk supply, then regulate feedingaccording to infant’s demands (feed effectively at least8 times per day).

Monitor the infant’s output for number of wet diapers.Document the number of diapers and the color ofurine. A well hydrated infant will have six to eight wetdiapers and at least three bowel movements every 24hours after day 4.5

Weigh the infant at least every third day and record.

Assist the mother in planning a day’s activities when breast-feeding to ensure that the mother gets sufficient rest.

Encourage advanced planning for the working mother ifshe intends to continue to breastfeed after returning towork.

Involve the father or significant other in breastfeeding byencouraging the “provider–protector” role.

Using a written scale is an excellent method of measuringthe self-efficacy of mothers who are breastfeeding, aswell as identifying high-risk mothers, build confidencein breastfeeding mothers, assess breastfeeding behav-iors, and evaluate the effectiveness of interventions.52

The majority of women who are successfully breast-feeding when leaving the hospital quit as soon asthey are home for 2 weeks. Support systems area critical component in the maintenance of suc-cessful lactation.41–43,52

Breastfeeding mothers should increase their caloric intaketo 2000 to 2500 calories/day in order to maintain suc-cessful lactation.5

Newborns need frequent feeding to satisfy their hungerand to establish their feeding patterns. It is importantthat the mother understand that the infant’s sucklingwill determine the supply and demand of breast milk.

Helps determine intake, hydration, and nutritional statusof infant.

Helps the new mother establish a schedule that is benefi-cial for both the mother and infant.41

The breastfeeding mother requires a great deal of supportand encouragement. Fathers can supply this by provid-ing her with time for rest and assistance with infantcare. For example, the father can bring the infant to themother at night rather than the mother having to get upeach time for the feeding. Fathers can intervene withfamily and friends to provide nursing mothers with pri-vacy and a quiet environment.

Mental Health

This diagnosis will not be applicable in a mental health setting.

Gerontic Health

This diagnosis is not applicable in gerontic health.

Home Health

The Home Health nursing actions for this diagnosis are the same as those for Women’s Health.


BREASTFEEDING, INEFFECTIVE

DEFINITION28

The state in which a mother, infant, or child experiences dis-satisfaction or difficulty with the breastfeeding process.


1. Unsatisfactory breastfeeding process2. Nonsustained sucking at the breast3. Resisting latching on4. Unresponsiveness to other comfort measures5. Persistence of sore nipples beyond the first week of

breastfeeding6. Observable signs of inadequate infant intake7. Insufficient emptying of each breast per feeding8. Inability of infant to attach onto maternal breast

correctly9. Infant arching and crying at the breast

10. Infant exhibiting fussiness and crying within the firsthour after breastfeeding

11. Actual or perceived inadequate milk supply12. No observable signs of oxytocin release13. Insufficient opportunity for sucking at the breast

RELATED FACTORS28

1. Nonsupportive partner or family2. Previous breast surgery3. Infant receiving supplemental feedings with artificial

nipple4. Prematurity5. Previous history of breastfeeding failure6. Poor infant sucking reflex7. Maternal breast anomaly8. Maternal anxiety or ambivalence9. Interruption in breastfeeding

10. Infant anomaly11. Knowledge deficit


1. Any diseases of the breast2. Cleft lip; cleft palate3. Failure to thrive4. Prematurity5. Child abuse


Ineffective BreastfeedingIneffective Breastfeeding should be differentiated fromthe patient’s concern over whether she wants tobreastfeed or not. Although a mother who does notwant to breastfeed will more than likely be ineffectivein her breastfeeding attempts, ineffective breastfeed-ing can be related to problems other than just unwill-ingness to breastfeed. Other diagnoses that need tobe differentiated include:

AnxietyAnxiety is defined as a vague, uneasy feeling, thesource of which is often nonspecific or unknown tothe individual. If an expression of perceived threat toself-concept, health status, socioeconomic status,role functioning, or interaction patterns is made, thiswould constitute the diagnosis of Anxiety.

Impaired ParentingImpaired Parenting is defined as the inability of thenurturing figures to create an environment that pro-motes optimum growth and development of anotherhuman being. Adjustment to parenting, in general, isa normal maturation process following the birth of achild.

Delayed Growth and Development:Self-Care SkillsThis diagnosis is defined according to a demonstrateddeviation from age group norms for self-care.Inadequate caretaking would be defined according tospecific behavior and attitudes of the individualmother or infant.

Ineffective Individual CopingThis diagnosis is defined as the inability of the indi-vidual to deal with situations that require coping oradaptation to meet life’s demands and roles. All thechanges secondary to the birth of a new baby couldresult in this diagnosis.

EXPECTED OUTCOME

Infant will require no supplemental feedings by [date].

TARGET DATES

Because Ineffective Breastfeeding can be physically detri-mental to the infant as well as emotionally detrimental to themother, an initial target date of 3 days is best.


••••••


Adult Health

For this nursing diagnosis, the Women’s Health nursing actions serve as the generic nursing actions.


Breastfeeding, Ineffective 149

••••••

Child Health


Monitor for factors contributing to the infant’s abilityto suck:

• Structural abnormalities (e.g., cleft lip or palate)• Altered level of consciousness, seizures, or CNS

damage• Mechanical barriers to sucking (e.g., endotracheal tube

or ventilator)• Pain or underlying altered comfort or medication• Prematurity with diminished sucking ability

Determine the effect the altered or impaired breastfeedinghas on the mother and infant by providing at least one30-minute period per day for talking with the mother.Monitor maternal feelings expressed, maternal–infantbehaviors observed, and excessive crying or unrelent-ing fussiness in the infant.

To the degree possible, provide emotional support for theinfant in instances of temporary inability to breastfeed(e.g., gavage feedings with appropriate cuddling).Include the parents in care. Allow the infant to suckon pacifier if possible.

Coordinate the parents’ visitation with the infant to bestfacilitate successful breastfeeding in such areas as rest,natural hunger cycles, and comfort of all involved.

Assist with plan to manage impaired breastfeeding to bestprovide support to all involved (e.g., breast-pumpingfor period of time with support for this effort until nor-mal breastfeeding can be resumed). Breast milk maybe frozen or even given in gavage feeding. Support themother’s choice for whatever alternatives are chosen.

Provide appropriate resources that may include local lac-tation specialist or in house assistance, plus those avail-able via the Internet, library, and book stores.

Assessment of the infant’s ability to suck assists in meet-ing goals for effective breastfeeding.

The maternal–infant responses provide the essential data-base in determining how serious the breastfeedingissues are. This information dictates how to approachthe problem and promote realistic follow-up.

Before attempting any formula feedings try various artifi-cial feeding techniques using the mother’s own milkfor the infant.51 Provides temporary substitutions forbreastfeeding that promote trust and sense of securityfor the infant. Also, bonding with the mother is stillpossible.50,51,53,54

Maintain the mother’s confidence in breastfeeding.Supporting her choice for alternative feeding demon-strates valuing of her beliefs.50,51,53,54

Women’s Health


Ascertain the mother’s desire to breastfeed the infantthrough careful interviewing and reviewing of themother’s knowledge of breastfeeding.

List the advantages and disadvantages of breastfeedingfor the mother.

Obtain a breastfeeding and bottle-feeding history fromthe mother (e.g., did she breastfeed before, and if so,was it successful or unsuccessful)?

Allow for uninterrupted breastfeeding periods.

Provides intervention base for nursing actions. Allowsplanning of support, teaching, and evaluation ofmotives and desires to breastfeed.

Assists the mother to make an informed decision aboutbreastfeeding.5,44,52

Providing the mother and infant with uninterruptedbreastfeeding times allows them to become acquaintedwith each other and allows time for learning differentbreastfeeding techniques.




••••••


Women’s Health


Collaborate with physician, lactation consultant, perinatalclinical nurse specialist, etc. to determine ways tomake abnormal breast structure amenable for breast-feeding.

Observe the mother with the infant during breastfeeding.Explain and demonstrate methods to increase infantsucking reflex. Demonstrate to the mother variouspositions for breastfeeding and how to alternate posi-tions with each feeding to prevent nipple soreness(e.g., sitting up, lying down, using football hold, hold-ing the baby “tummy to tummy,” using pillows for themother’s comfort, or using pillows for supporting thebaby).

Ascertain the mother’s need for privacy during breast-feeding.

Monitor for poor or dysfunctional sucking by checking:• Position the mother is using to hold the baby• Baby’s mouth position on areola and nipple• Position of the baby’s head (e.g., inappropriate hyper-

extension)

Ascertain the mother’s support for breastfeeding fromothers (e.g., husband or significant other, patient’sfemale family members, obstetrician, pediatrician,and nurses on postpartum unit).

Discuss the infant’s needs and frequency of feedings.

Assist the mother in planning a day’s activities whenbreastfeeding, ensuring that the mother gets plentyof rest.

Teach the patient:• The proper diet for the breastfeeding mother, listing

important food groups and necessary calories to ade-quately maintain milk production.

• The idea of advanced planning for the working motherwho plans to breastfeed

• That it takes time to establish breastfeeding (usually amonth)

• The use of various hand pumps, battery-operatedpumps, and electric pumps

• How to hand-express breast milk• How to store expressed breast milk properly

Schedule specific times for consultation and support forthe mother. Plan at least 30 minutes per shift (whileawake) for talking with the mother.

Assists the mother who has strong desire to breastfeed tobe successful.

Provides basic information and visible support to assistwith successful breastfeeding.

Promotes the mother’s comfort with the physical act ofbreastfeeding.

Proper positioning facilitates satisfaction with breastfeed-ing for both the mother and baby.

Support from others is essential for attaining successfulbreastfeeding. Success or failure to breastfeed isstrongly influenced by family and community, theirvalues and beliefs. Sisters, aunts, mothers, and grand-mothers play a large role in breastfeeding success. Todetermine the basis for assistance and teaching isessential in order to avoid nonessential repetition andconfusion for the mother.41–43


Provides information necessary for the mother to plan thebasics of her self-care.

The breastfeeding woman can generally meet her nutri-tional needs and those of her infant through adequatedietary intake of food and fluids; however, because theenergy demand is greater during lactation, RDA stan-dards recommend an additional 200 to 500 extra calo-ries per day to be added to the diet to provide adequatenutrients for both mother and infant without catabolismof the mother’s lean tissue.5


Breastfeeding, Ineffective 151

••••••


If the baby is separated from the mother, such as inneonatal intensive care unit (NICU), involve the baby’snurses in planning with the mother routines and timesfor breastfeeding the infant.50,51

Refer the mother to breastfeeding support groups.

For the mother who has had a cesarean section, place apillow over the abdomen before putting the infant tothe breast.

Breastfeeding after breast surgery:• Prenatal nipple and breast assessment along with his-

tory and description of breast surgery• Teach appropriate interventions for mother’s use.• Supplemental methods of feeding (using a supplemen-

tal nursing system)• Ensure that mothers know how to assess for infant

dehydration.• Sunken anterior fontanel• Weak, high-pitched cry and insufficient and infrequent

wet diapers (early days—one or two wet diapers per day;after days 3 and 4—six to eight wet diapers per day)

• Availability of galactogogues (increase milk supply).Should be taken only when a low milk supply is docu-mented by the mother.55

Assist the mother of a premature baby to pump breastroutinely to initiate milk production.

Demonstrate proper storage and transportation of breastmilk for the premature baby.

Assist the mother who has to wean a premature babyfrom tube feedings to breastfeeding by:

• Teaching the mother to place the infant at the breastseveral times a day and during tube feeding

• Encouraging the mother to hold, cuddle, and interactwith the infant during tube feedings

• Allowing the mother and infant privacy to begininteraction with breastfeeding

• Being available to assist with the infant duringbreastfeeding interaction

• Reassuring the mother that it might take severalattempts before the baby begins to breastfeed

Give breastfeeding mothers copies of educationalmaterials.

If breastfeeding is not possible because of an infant phys-ical deformity, teach the mother how to pump breastsand how to feed the infant breast milk in bottles withspecial nipples.

Encourage maternal attachment behavior by not separat-ing mother and baby after birth.


Assists in keeping pressure off the incision line whilebreastfeeding.

Research has shown that breast surgery may not have animpact on a women’s ability to breastfeed as much asthe support around her.41,55

See effective breastfeeding diagnosis for correct pumpsetup for these mothers.

Basic teaching to ensure safe nutrition for infant.

Provides needed support during this process.

Provides a readily available information source.

Allows the mother the option of breastfeeding in theevent that the deformity can be surgically corrected.

Assists the mother in adjustment to parenting and effec-tive caretaking of the infant.

Mental Health

Refer to Women’s Health nursing actions for interventions related to this diagnosis.(care plan continued on page 152)


BREASTFEEDING, INTERRUPTED

DEFINITION28

A break in the continuity of the breastfeeding process as aresult of inability or inadvisability to put the baby to thebreast for feeding.30


1. Infant not receiving nourishment at the breast for someor all feedings

2. Lack of knowledge regarding expression and storage ofbreast milk

3. Maternal desire to maintain lactation and provide (oreventually provide) her breast milk for her infant’s nutri-tional needs

4. Separation of the mother and infant

RELATED FACTORS28

1. Contraindications to breastfeeding (e.g., drugs or truebreast milk jaundice)

2. Maternal employment3. Maternal or infant illness4. Need to abruptly wean infant5. Prematurity


1. Any condition requiring emergency admission of themother to hospital

2. Any condition requiring emergency admission of theinfant to hospital

3. Prematurity4. Postpartum depression


Ineffective BreastfeedingIneffective Breastfeeding is expressed dissatisfactionor problems with breastfeeding. With InterruptedBreastfeeding, there is no expressed dissatisfaction ormajor problems; however, Breastfeeding has tem-porarily ceased as a result of factors beyond themother’s control.

Ineffective Infant Feeding PatternIn this diagnosis, there is a defined problem with theinfant’s ability to suck, swallow, and breathe.Breastfeeding for this infant has not ever been suc-cessful. With Interrupted Breastfeeding, the infant hasno problems with sucking or swallowing, and thestoppage of breastfeeding can be overcome by stor-ing breast milk and feeding the infant via a bottle.

EXPECTED OUTCOME

Infant will demonstrate no weight loss secondary to adapta-tions for Interrupted Breastfeeding by [date].

TARGET DATES

Because this interruption might occur as a result of an emer-gency, initial evaluation should occur within 24 hours afterthe initial diagnosis. Thereafter, target dates can be moved toevery 3 days.


••••••


Gerontic Health

This diagnosis is not appropriate for gerontic health.



Assist the client and family in identifying risk factorspertinent to the situation:

• Premature infant• Infant anomaly• Maternal breast dysfunction• Infection• Previous breast surgery• Supplemental bottle feedings• Nonsupportive family• Lack of knowledge• Anxiety

Consult with, or refer to, appropriate communityresources as indicated (e.g., WIC).

Identification of and early interventions in high-risk situa-tions provide the opportunity to prevent problems.

Appropriate and cost-effective use of available resources.


Breastfeeding, Interrupted 153

••••••

Child Health


Monitor for infant’s ability to suck. Encourage suckingon a regular basis, especially if gavage feedings are apart of the therapeutic regimen.

Provide support for the mother–infant dyad to facilitatebreastfeeding satisfaction.

Monitor infant cues suggesting satisfaction:• Weight gain appropriate for status• Ability to sleep at intervals

Provides basic data critical to success. In times of non-breastfeeding, it is beneficial to encourage sucking toreinforce the feeding time as pleasurable and toenhance digestion, unless contraindicated by a surgicalor medical condition (e.g., cleft repair of lip or palate,prolonged NPO [nothing by mouth] status with con-cerns for air swallowing).

Feedback may provide essential valuing during times ofstress.

The fact that the infant’s satisfaction and input are valuedprovides a critical component in the entire process ofbreastfeeding.

Women’s Health


Provide appropriate information on why breastfeedingneeds to be interrupted. Be specific about length oftime (i.e., days, weeks, or months), and offer optionsfor maintaining breast milk until able to resume breast-feeding.49-51,53

Describe routine for pumping, expressing, and storing ofbreast milk during emergency period.

Contact lactation consultant and/or perinatal nurse whocan assist with plan of nursing care and with mainte-nance of breast milk during mother’s illness (e.g.,emergency surgery, medical regimen [medications] thatcontradict breastfeeding, or injury requiring hospital-ization of mother).45,46

Provide the mother with appropriate information aboutbreast pumps and how to obtain one (rent or buy) toaid in expression of breast milk (i.e., semiautomaticbreast pump, automatic breast pump, battery-operatedbreast pump, or manual breast pump).

Demonstrate and have the mother return-demonstrateproper assembly and use of breast pump.

Assist the mother in learning manual expression of breastmilk.46

• Good handwashing technique before expressing milk• Correct positioning of hand and fingers so as not to

damage breast tissue

Assists breastfeeding families in establishing and main-taining breastfeeding capabilities when it is inadvis-able or impossible to put the baby to the breast forfeeding.


Adult Health

Refer to Women’s Health for appropriate interventions.




••••••


Women’s Health


• Sterile wide-mouth funnel and bottle for storage ofbreast milk

Discuss options for maintaining breastfeeding with themother who is returning to work. Provide assistance tohelp the mother establish feeding schedule with workschedule (e.g., breastfeed a.m. and p.m., pumping atnoon, etc.)45,46,56

Provide resources (e.g., printed materials or consultant) toassist the mother when negotiating with her employerfor time and place to pump or breastfeed during work-ing hours.46

Assist the mother and family to arrange schedule to bringthe infant to her during working hours.

Encourage the mother and significant other to verbalizetheir frustrations and concerns about establishing andmaintaining lactation when the infant is ill or prema-ture.47,50,51,53

Refer to lactation consultant/clinical nurse specialist whocan support the parents and assist the nurse in develop-ing a program of breastfeeding or supplementing of theinfant with the mother’s breast milk.53–55

Provides basic information that assists in promotingeffective breastfeeding.

Mental Health

● N O T E : This diagnosis will not, in all likelihood, be applicable in a mental healthsetting. Should a mother be admitted with a mental health–related diagnosis, the physi-cian would probably suggest changing the infant to bottle-feedings. Should the physicianagree that breastfeeding could continue, the Women’s Health actions would be applica-ble for the mental health client.


● N O T E : If home care is needed because of either mother or infant illness or disability,the nurse will need to address the underlying problem in order to promote EffectiveBreastfeeding. It is not likely that home health care would be initiated if the only diagno-sis was Ineffective Breastfeeding; however, there are lactation consultants whose entirepractice is home health. This practice has been specifically designed to assist with main-tenance of successful lactation.


Gerontic Health

This diagnosis is not appropriate for gerontic health.

Support the mother, infant, and family dynamics for suc-cessful breastfeeding.

Encouragement and support increase the potential forpositive outcomes.


DENTITION, IMPAIRED

DEFINITION28

Disruption in tooth development, eruption patterns, or struc-tural integrity of individual teeth.30


1. Excessive plaque2. Crown or root caries3. Halitosis4. Tooth enamel discoloration5. Toothache6. Loose teeth7. Excessive calculus8. Incomplete eruption for age (may be primary or perma-

nent teeth)9. Malocclusion or tooth misalignment

10. Premature loss of primary teeth11. Worn down or abraded teeth12. Tooth fractures13. Missing teeth or incomplete absence14. Erosion of enamel15. Asymmetric facial expression

RELATED FACTORS28

1. Ineffective oral hygiene2. Sensitivity to heat or cold3. Barriers to self-care4. Access or economic barriers to professional care5. Nutritional deficits6. Dietary habits7. Genetic predisposition8. Selected prescription medications9. Premature loss of primary teeth

10. Excessive intake of fluoride11. Chronic vomiting

12. Chronic use of tobacco, coffee, tea, or red wine13. Lack of knowledge regarding dental health14. Excessive use of abrasive cleaning agents15. Bruxism


1. Dental surgery2. Elderly wearing dentures3. Facial trauma4. Anorexia or bulimia5. Malnutrition


Imbalanced Nutrition, Less Than BodyRequirementsImpaired Dentition might be a primary factor in thedevelopment of Imbalanced Nutrition, Less Than BodyRequirements. Impaired Dentition is a very specificdiagnosis related only to the teeth and would requireintervention before working on the broader diagnosisof Imbalanced Nutrition, Less Than BodyRequirements.

Adult Failure to ThriveAgain, Impaired Dentition might contribute to thedevelopment of Adult Failure to Thrive. This meansImpaired Dentition would need to be resolved beforethe broader definition of Adult Failure to Thrive.

EXPECTED OUTCOME

Will return-demonstrate complete oral hygiene by [date].

TARGET DATES

One week would be an appropriate time period to check ini-tial progress toward resolving this problem area.

Dentition, Impaired 155

••••••


Recognize cultural variations in feeding practices whenassessing effectiveness of breastfeeding.

Provide additional education or referrals as requested oras the situation changes.

Feeding patterns vary according to cultural norms.

Community-based support is ongoing; early interventionas the situation changes increases the potential for con-tinued effectiveness. Support from others is essential inattaining successful breastfeeding. Success or failure tobreastfeed is strongly influenced by family and commu-nity, their values and beliefs. Sisters, aunts, mothers,and grandmothers play a large role in breastfeedingsuccess. Determining the basis for assistance and teach-ing is essential in order to avoid nonessential repetitionand confusion for the mother.41–43



••••••


Adult Health


Educate and provide patient with well-balanced dietincluding fiber.

Assist the patient with oral hygiene at least after mealsand at bedtime.

If Impaired Dentition predisposes to ImbalancedNutrition, Less Than Body Requirements, refer to thatnursing diagnosis.

If Impaired Dentition predisposes to ImbalancedNutrition, More Than Body Requirements, refer to thatnursing diagnosis.

If Impaired Dentition is related to chronic vomiting, referto the nursing diagnosis for Nausea or Disturbed BodyImage and/or Alteration in Nutrition, Less than BodyRequirements Psychiatric Care Plan.

If Impaired Dentition is related to chronic use of tobacco,coffee, tea, or red wine, educate the patient in methodsto stop this usage. [Note education plan here.]

Consult with dietitian to provide soft, nonmechanicaldiet.

Consult with social worker to help the patient find afford-able access to professional dental care.

Teach the patient about dental health.

Refer to a dentist.

Consult oral surgeon if extraction is deemed necessary.

Provides essential nutrition.

Cleans and lubricates the mouth.

Impaired Dentition related to chronic vomiting can be asymptom of an eating disorder and the client needs tobe assessed for this.

Encourages health promotion and decreases factorsrelated to Impaired Dentition.

Makes food easier to chew, thereby encouraging essentialnutrition.

Assists in preventive maintenance and good oral health.

Child Health


Monitor for all possible contributing factors to include,but not limited to, organic, genetic, familial, medical,prenatal, or neonatal factors; prematurity; jaundice;significant injuries or exposures; and nutritional possi-bilities.

Determine whether there are coexistent congenital anom-alies or risk factors.

• Risk for caries increased by the infant or toddler beinggiven fruit juices or high corn syrup/fructose contentbeverages, especially in a bottle.

Identify current dental hygiene for the client (expecta-tions according to age norms; e.g., 6 months—gentlecleansing of gums with soft cotton cloth).

• Teach the child and significant others practices thatincrease the risk of caries.

Monitor the mouth fully for status of gums and teeth, ifpresent, type and location, condition of enamel, andalignment or malocclusion.

Consideration of all possible etiologies best helps identifytreatment modalities.

Primary deficits may exist in isolation or in combinationwith other deficits.

Preventive maintenance knowledge offers a baseline forhygiene routines and reduction of risk factors for age.

Actual observation assists in accuracy of diagnosis andtreatment.


Dentition, Impaired 157

••••••


Gerontic Health


Determine the client and/or caregiver’s ability to performoral hygiene measures.

Review and/or teach the client strategies for good oralhygiene as necessary (i.e., daily flossing, brushing aftermeals, and using correct equipment [soft-bristled toothbrush]).54

Refer the client to an occupational therapist, if needed,for assistive equipment and techniques to enhance oralhygiene practices.57

Advocate for clients to ensure access to dental services.

Physical aging changes associated with chronic diseasesuch as arthritis may limit the ability to perform oralcare.56

Many older adults have not been taught how to ade-quately clean their teeth by brushing and flossing.56

Older adults may experience problems with grippingtoothbrushes or using dental floss, and thus adequateoral care is inhibited.57

Many older adults are reluctant to use dental servicesbecause of cost concerns.58

Mental Health

The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health.

Women’s Health

Nursing interventions for Women’s Health are the same as those for Adult Health.

● N O T E : It is important to practice good dental health during pregnancy. A pregnantwoman needs approximately 1.2 g of calcium and phosphorus daily during pregnancy tohelp maintain bony stores.

Determine pattern of tooth appearance and correlation tonorms for primary and secondary teeth.

Determine patterns of tooth loss according to norms forprimary and secondary teeth.

Make appropriate recommendations for maintenance,prophylactic, and restorative care of the client’s teethand gums.

Offer appropriate education for safeguarding permanentteeth for the client and family, to include indicationsfor mouth guards during contact sports, ways to mini-mize risk of injury, and importance of seeking immedi-ate attention of dentist in event of accidental loss oftooth.

Ascertain client and parental knowledge regarding med-ications, dietary factors, special orthodontia, or otherrelated maintenance issues.

Provide information for local support groups when appli-cable (e.g., Dental Association).

Determine resources for continued maintenance, includ-ing financial, as determined on an individual basis.

• Refer to community resources to facilitate continuedmaintenance of dental health.

Expected norms assist in identification of deviations.

Expected norms assist in identification of deviations.

Appropriate referral to specialists offers maximum poten-tial for long-term maintenance of dentition health.

Anticipatory planning assists in dentition health main-tenance.

Validation of actual knowledge or care issues affordsoptimum likelihood of adherence to regimen for theindividual client.

Support groups foster shared experience with validationof peer input.

Resources help provide appropriate care as situationpermits.



FLUID BALANCE, READINESSFOR ENHANCED

DEFINITION28

A state in which an individual’s pattern of equilibriumbetween fluid volume and chemical compositions of bodyfluids is sufficient for meeting physical needs and can bestrengthened.


1. Expresses willingness to enhance fluid balance2. Stable weight3. Moist mucous membranes4. Food and fluid intake adequate for daily needs5. Straw-colored urine with specific gravity within normal

limits6. Good tissue turgor7. No excessive thirst

8. Urine output appropriate for intake9. No evidence of edema or dehydration

RELATED FACTORS

None listed.


Illness that has potential of impacting fluid balance


Risk for Imbalanced Fluid VolumeIndicates a potential for fluid shifts.

Readiness for Enhanced Fluid BalanceReadiness for Enhanced Fluid Balance is the moreappropriate diagnosis for patients who are starting toexhibit behaviors that demonstrate the ability to main-tain adequate fluid balance.


••••••


Gerontic Health


If dentures are present, monitor for appropriate fit, bed-time removal of dentures, and presence of food trap-ping under dentures after meals.

There is continuous resorption of ridges beneath denturesover time, causing a slow change in how well denturesfit. Failure to remove dentures at bedtime may result inoral trauma or breathing problems if the dentures areloose. Food trapping can lead to mucosal inflammationfrom organisms trapped under dentures.56



Assist the client in obtaining dentures when appropriate.

Assist the client in replacing poorly fitting dentures whennecessary. Older clients will require correction of den-ture fit every few years.

Teach the client proper oral care:• Brushing teeth after each meal• Vigorous mouth rinsing• Flossing at least once daily

Teach the client appropriate dietary modifications:• Reducing refined carbohydrates• Reducing between-meal snacks

Assist the client in obtaining oral care products asnecessary.

Educate clients about signs and symptoms of tooth decayand periodontal disease and when to seek medical ordental care.

Assists the client to increase nutritional intake andimprove appearance.

Decreases multiple problems created by poorly fittingdentures.

Prevents exacerbation of existing conditions.

Encourages proper oral hygiene.

Encourages self-care and prevention.


Fluid Balance, Readiness For Enhanced 159

••••••

Child Health

Oral rehydration offers a realistic treatment option for mild and moderate dehydration and often is suited to home asopposed to hospital management.58


Monitor for all contributory patterns to provide a basisfor fluid and electrolyte needs, especially prior 24-hourintake and output, losses per stool, surgical losses, andpost-op drainage.

Offer fluids according to plan-see that fluids and elec-trolytes are offered according to hydration needs*(based on metabolic requisites for size by surface areacalculations). Clarify with pediatrician, nurse practi-tioner, or primary care physician. May also consult

Provides fullest database for considering plan forsuccess.

Appropriate fluid amount and composition will best sat-isfy rehydration needs according to dehydration risk.*

EXPECTED OUTCOME

The client will demonstrate enhanced fluid balance by[date].

Demonstrates balance in 24-hour intake and output.Verbalizes [number] of lifestyle adaptations that will

enhance fluid balance by [date].

TARGET DATES

Client education and support are key interventions forReadiness for Enhanced Fluid Balance. Since the client isalready demonstrating positive behaviors, it is recom-mended that target dates be no further than 3 days from thedate of initial diagnosis.


Adult Health


Assist the patient in documenting plan for adequate fluidintake including types and amounts of fluids.

Educate patient to obtain necessary information fromfood labels.

Have patient verbalize appropriate choices for fluidintake.

Educate patient in regard to adjusting fluid intakerelative to physical activity, disease processes, andmedications.

Educate patient regarding signs and symptoms of fluidimbalances: dependent edema, shortness of breath,concentrated urine, dry mucous membranes, decreasedskin turgor, urinary tract infections.

Have patient document weight on a daily basis.

Follow-up with patient 3 days after initial diagnosis.

Educate patient regarding signs and symptoms of fluidimbalances: dependent edema, concentrated urine, drymucous membranes, decreased skin turgor, urinarytract infections.

Have patient to document weight on a daily basis to assistin trending.

Follow-up with patient 3 days after initial diagnosis.

Assures that devised plan has food choices based ondietary guidelines.

Assists patient in making appropriate fluid intake choicesbased on content.

Demonstrates patient understanding of appropriate fluidsfor consumption.

Gives patient fundamental basis for decision making.

Assists in trending progress.

Allows to monitor progress and adjust plan as necessary.

Allows to monitor progress and adjust plan as necessary.




••••••


Child Health


Harriet Lane handbook with a desired urinary outputof 2 mL/kg minimally.59 [Note those fluids preferredby the child here.]

Teach the family to have appropriate fluid and electrolytesolutions including Pedialyte, Infalyte, Resol, Lytren,Nutrilyte, and others, on hand.

Avoid simple sugars, such as soft drinks or Kool-Aid.

Monitor for tolerance of fluid and avoid overfeeding—small feedings regularly are better tolerated.

Reassess for hydration status with a focus on urinary out-put of 2 mL/kg, minimally, level of consciousness, skinturgor, and anterior fontanel status for infants.

Maintain strict intake and output for the duration of therehydration experience.

Reassess the caregiver’s knowledge for need for rehydra-tion. [Note teaching needs and plan here.]

Provides guidance for future situations.

Osmotic effects may worsen diarrhea.

Lessens likelihood of increased intolerance during initialrehydration phase.

Offers a record for evaluation of effectiveness of plan.

Provides anticipatory guidance.59

Women’s Health

The nursing actions for the women’s health client with this diagnosis are the same as those for the adult health clients andgerontic health clients. For breastfeeding women, see Effective Breastfeeding diagnosis.

Mental Health

The nursing actions for the mental health client with this diagnosis are the same as those for the Adult Health client.

Gerontic Health

● N O T E : Dehydration has been reported to be the most common fluid and electrolyteimbalance in older people. Hospitalized elders with dehydration have mortality rates ashigh as 46 percent. Elders are particularly susceptible to dehydration because of age-related changes such as decreased renal perfusion and sensitivity to antidiuretic hor-mone (ADH), decreased sense of thirst, decreased mobility, and confusion. In addition,some pathological conditions; such as hypertension and heart and renal disease, makeelders highly susceptible to fluid and electrolyte imbalances.60

In addition to the interventions for Adult Health, the following may be utilized for the aging client:


Facilitate client receiving at least 1500 cc/day of oralintake.

Regularly and frequently monitor dependent and semide-pendent clients for adequate fluid intake. These clientsshould be considered for a restorative fluid program.

Utilize a fluid intake sheet to monitor daily fluid intake.

Less than this can lead to rapid dehydration.

Preventive practice.

Tracks oral intake and allows for early identification ofless than optimal intake.


Fluid Volume, Deficient, Risk For and Actual 161

••••••


Regularly and frequently present fluids to bedriddenclients. [Note the client’s preferred fluids here.]

Utilize medication time to encourage increased fluid intake.

Facilitates maintenance of adequate hydration status.

Medication time can be an important source of fluids.60


In addition to the interventions for Adult Health, the following may be utilized in the community setting:


Monitor the patient’s ability to access and pay for ade-quate beverages. Refer to community resources asappropriate.

Monitor the patient’s ability to obtain adequate bever-ages. When travel or mobility issues are present, referto community resources.

Teach the caregiver and client to maintain oral fluidintake of at least 1500 cc/day.

Adequate resources facilitate adherence to plan of care.Promotes self-care.


Minimal amount of fluid required to maintain adequatehydration status.

FLUID VOLUME, DEFICIENT,RISK FOR AND ACTUAL

DEFINITIONS28

Risk for Deficient Fluid VolumeThe state in which an individual is at risk of experienc-ing vascular, cellular, or intracellular dehydration.

Deficient Fluid VolumeThe state in which an individual experiencesdecreased intravascular, interstitial, and/or intracellu-lar fluid. This refers to dehydration, water loss alonewithout change in sodium.


A. Risk for Deficient Fluid Volume1. Factors influencing fluid needs (e.g., hypermetabolic

state)2. Medications, for example, diuretics3. Loss of fluid through abnormal routes (e.g.,

indwelling tubes)4. Knowledge deficiency related to fluid volume5. Extremes of age6. Deviations affecting access to or intake or absorption

of fluids (e.g., physical immobility)7. Extremes of weight8. Excessive losses through normal routes, for example,

diarrheaB. Deficient Fluid Volume

1. Weakness2. Thirst3. Decreased skin/tongue turgor4. Dry skin/mucous membranes

5. Increased pulse rate, decreased blood pressure,decreased pulse volume/pressure

6. Decreased venous filling7. Change in mental state8. Decreased urine output9. Increased urine concentration

10. Increased body temperature11. Elevated hematocrit12. Sudden weight loss (except in third spacing)

RELATED FACTORS28

A. Risk for Deficient Fluid VolumeThe risk factors also serve as the related factors for this

diagnosis.B. Deficient Fluid Volume

1. Active fluid volume loss2. Failure of regulatory mechanisms


1. Addison’s disease (adrenal insufficiency or crisis)2. Hemorrhage3. Burns4. AIDS5. Crohn’s disease6. Vomiting and diarrhea7. Ulcerative colitis


Impaired Oral Mucous Membrane and Imbal-anced Nutrition, Less than Body RequirementsThe client may not be able to ingest food or fluidbecause of primary problems in the mouth, or the

(box continued on page 162)


Have You Selected the Correct Diagnosis? (box

continued from page 161)

client just may not be ingesting enough food fromwhich the body can absorb fluids.

Bowel Incontinence, Diarrhea,or Urinary IncontinenceThese diagnoses may be causing an extreme loss offluid before it can be absorbed and used by the body.

Impaired Skin IntegrityThis diagnosis could be the primary problem. Forexample, the patient who has been burned hasgrossly impaired skin integrity. The skin is supposedto regulate the amount of fluid lost from it. If there isrelatively little intact skin, the skin is unable to performits regulatory function and there is significant loss offluid and electrolytes.

Self-Care Deficit or Impaired ParentingIn the infant or young child, the problem may primarilybe a Self-Care Deficit or Impaired Parenting. The

infant or young child is not able to obtain the fluid heor she wants and must depend on others. If the par-ents are unable to recognize or meet these needs,then the infant or young child may have a Risk for orActual Deficient Fluid Volume. Even in an adult, theprimary nursing diagnosis may be Self-Care Deficit.Again, if the adult is unable to obtain the fluid he orshe requires because of some pathophysiologic prob-lem, then he or she may have a Risk for or ActualDeficient Fluid Volume.

EXPECTED OUTCOME

Intake and output will balance within 200 mL by [date].

TARGET DATES

Normally, intake and output will approximately balanceonly every 72 hours; thus, an appropriate target date wouldbe 3 days.


••••••


Adult Health


Take vital signs every 2 hours on [odd/even] hour andinclude apical pulse.

Carefully observe any surgical sites for signs of bleeding,hematomas, etc.

• Observe for signs and symptoms of shock at least every1 hour at [state times here] (e.g., weakness, diaphore-sis, hypotension, tachycardia, or tachypnea).

Measure and record total intake and output every shift:• Check intake and output hourly.• Document amount and quality of all urine, stools, and

vomitus.• Check urine specific gravity every 4 hours at [state

times here].Monitor intravenous fluids in conjunction with I & O.

(See Additional Information for Imbalanced Nutrition,Less Than Body Requirements.)

Monitor:• Mental status and behavior at least every 2 hours on the

[odd/even] hourWeigh daily at [state time here]. Teach the patient to

weigh at the same time each day in same-weightclothing.

• Skin turgor at least every 4 hours at [state times here]while awake

• Electrolytes, blood urea nitrogen, albumin hematocrit,and hemoglobin (Collaborate with health-care providerregarding frequency of laboratory tests.)

• Central venous pressure every hour, if appropriate

Essential to monitoring of cardiovascular response to ill-ness state and replacement therapy.

Determines extent of fluid loss, need for replacement, orprogress of replacement therapy.

Monitoring of fluid replacement and prevention of fluidoverload.

Monitoring for fluid replacement. Allows consistent com-parison of weight.

Essential to determining potential contributing factors tofluid imbalance.



••••••


Force fluids to a minimum of 2000 mL daily: Offer smallamount of fluid (4 to 5 ounces) at least every hourwhile awake and at every awakening during night.[Note client’s fluid preferences here.]

• Interspace fluids with high-fluid-content foods (e.g.,popsicles, gelatin, pudding, ice cream, or watermelon).Avoid beverages with diuretic effects.

Collaborate with health-care team to determine medica-tions that address source of fluid loss (e.g., antidiar-rheals or antiemetics).

Assist the patient to eat and drink as necessary. Providepositive verbal support for the patient’s consumingfluid.

Monitor and address insensible fluid losses.Monitor gastric tubes to suction for large amounts of

gastric drainage. Initiate replacements if necessary.Teach the patient, prior to discharge, to increase fluid

intake at home during:• Elevated temperature episodes• Periods when infection and elevated temperatures are

present• Periods of exercise• Hot weather

Measures to ensure adequate hydration:• Need to drink fluids before feeling of thirst is experi-

enced• Recognizing signs and symptoms of dehydration such

as dry skin, dry lips, excessive sweating, dry tongue,and decreased skin turgor

• How to measure, record, and evaluate intake and outputRefer to other health-care professionals as necessary.

Prevents dehydration and easily replaces fluid loss with-out resorting to IVs. Frequent fluids improve hydra-tion; variation in fluids is helpful to encourage thepatient to increase intake.

Support the patient’s self-care by pointing out measureshe or she can use to control fluid imbalance. Adequateintake and early intervention will prevent undesirableoutcomes.

Provides support and fosters collaboration through use ofreadily available resources.

Child Health


Measure and record total intake every shift and note 24-hour totals:

• Check intake and output hourly (may require weighingdiapers or insertion of a Foley catheter [infants mayrequire use of a 5 or 8 feeding tube if size 10 Foley istoo large]).

• Check urine specific gravity every 2 hours on [odd/even]hour or every voiding or as otherwise ordered.

Force fluids to a minimum appropriate for size (will beclosely related to electrolyte needs and cardiac, respira-tory, and renal status). [Note fluids preferred by childhere.]

• Infants: 70 to 100 mL/kg in 24 hours• Toddler: 55 to 70 mL/kg in 24 hours• School-age child: 20 to 50 mL/kg in 24 hours

A 24-hour fluid assessment is meaningful for diagnosingdeficits and also provides a basis for replacementneeds.

Specific gravity is a good indicator of degree ofhydration.

Prompt replacement and maintenance of appropriatefluids prevents further circulatory or systemic prob-lems. Specific attention is also required with respectto sodium, potassium, and caloric intake. Infants aresubject to fluid volume depletion because of their rela-tively greater surface area, higher metabolic rate, andimmature renal function.61




••••••


Child Health


Weigh the patient daily at the same time of day, on thesame scale, and in the same clothing (weigh infantswithout diaper).

Assist in individualizing oral intake to best suit thepatient’s needs and preferences. Include parents indesigning this plan.

Accuracy of weight cannot be overstressed. The weightoften serves as a major indicator of the effectiveness ofthe treatment regimen. Iatrogenic problems are morelikely to occur with inaccuracies.

When options exist, honoring them facilitates better com-pliance with goals and helps the patient and family tofeel valued.

Women’s Health


Assist the patient to identify lifestyle factors that could becontributing to symptoms of nausea and vomiting dur-ing early pregnancy.

• Eat small, frequent meals.• Eat dry toast or crackers before arising.• Avoid foods with bothersome smells.• Avoid rich, fatty foods, spicy foods, and greasy foods.• Drink fluids separately from meals.• Drink herbal teas (raspberry leaf or peppermint).• Suck on a cinnamon stick.

Identify the patient’s support system.

Monitor the patient’s feelings (positive or negative) aboutpregnancy.

Evaluate social, economic, and cultural conditions.

Involve significant others in discussion and problem-solving activities regarding physiologic changes ofpregnancy that are affecting work habits and interper-sonal relationships (e.g., nausea and vomiting).

Teach the patient measures that can help alleviate patho-physiologic changes of pregnancy.

In collaboration with the dietitian:• Obtain dietary history.• Assist the patient in planning diet that will provide

adequate nutrition for her and her fetus’s needs.

Teach methods of coping with gastric upset, nausea, andvomiting:

• Eat bland, low-fat foods (no fried foods or spicyfoods).

• Increase carbohydrate intake.• Eat small amounts of food every 2 hours (avoid empty

stomach).• Eat dry crackers or toast before getting up in the

morning.• Take vitamins and iron with night meal before going to

bed (vitamin B, 50 mg, can be taken twice a day butnever on an empty stomach).

Provides basis for treatment of symptoms and basis forteaching and support strategies.

There are homeopathy methods of controlling nausea andvomiting of pregnancy including yoga, acupuncture,and rearranging eating patterns during the first 3 to4 months of pregnancy.5,62,63

Provides information, education, and support for self-careduring pregnancy. There are homeopathy methods ofcontrolling nausea and vomiting of pregnancy includ-ing yoga, acupuncture, and rearranging eating patternsduring the first 3 to 4 months of pregnancy.5,62,63



••••••

• Drink high-protein liquids (e.g., soups or eggnog).5,62,63

• Avoid foods with bothersome smells.• Avoid rich, fatty foods, spicy foods, and greasy foods.• Drink fluids separately from meals• Drink herbal teas (raspberry leaf or peppermint).• Suck on a cinnamon stick.5,62,63

Monitor the patient for:• Variances in appetite• Vomiting between 12 and 16 weeks of pregnancy• Weight loss• Intractable nausea and vomiting

Collaborate with physician regarding monitoring for:Dehydration• Electrolyte imbalance: hemoconcentration, ketosis with

ketonuria, hyponatremia, hypokalemia

Provides basis for therapeutic intervention if necessary aswell as support of that patient, which can decrease fearand feelings of helplessness.

Provides support and information to increase self-awareness and self-care.

● N O T E : “During pregnancy, gastric acid secretion normally is reduced because ofincreased estrogen stimulation. This places the women at risk for alkalosis, rather thanthe acidosis that usually occurs in an advanced stage of dehydration.”64

● N O T E : “Vitamin B6 has been found effective and safe for use in nausea and vomitingof pregnancy.”5

• Hydration (approximately 3000 milliliters/24 hours)and providing vitamin supplements

• Restriction of oral intake and providing parentaladministration of fluids and vitamins.

Provides information that allows for successful lactationand healthy recovery from childbirth.

Feeding behavior is important not only for fluid but alsofor food. The caloric need of the infant for the first 3months is 110 kcal/kg per day, from 3 to 6 months 100kcal/kg per day, and from 6 to 9 months 95 kcal/kg perday.5 Breast milk contains adequate nutrients and vita-mins for 6 months of life. The American Academy ofPediatrics recommends breastfeeding exclusively forthe first 6 months of life and continue breastfeedingwith other food induction for at least 12 months.5

Provides information and support for healthy growth anddevelopment of the newborn.

Allow expression of feelings and encourage verbalizationof fears and questions by scheduling at least 30 min-utes with the patient at least once per shift.

Provide the patient and family with diet information forthe breastfeeding mother to prevent dehydration:

• Increase daily fluid intake.• Drink at least 2000 mL of fluid daily.• Extra fluid can be taken just before each breastfeeding

(e.g., water, fruit juices, decaffeinated tea, or milk).• Eat well-balanced meals to include the basic food groups.

Teach the parents fluid intake needs of the newborn.

Monitor the newborn for fluid deficit, and teach the par-ents to monitor via the following factors:

• “Fussy baby,” especially immediately after feeding• Constipation (remember, breastfed babies have fewer

stools than formula-fed babies)• Weight loss or slow weight gain

Evaluate the baby, mother, and nursing routine:• Is the baby getting empty calories (e.g., a lot of water

between feedings)?(care plan continued on page 166)




••••••


Women’s Health


• Monitor the baby for nipple confusion from switchingthe baby from breast to bottle and vice versa manytimes.

• Count the number of diapers per day (should have sixto eight very wet diapers per day).

• Monitor the infant for intolerance to the mother’s milkor bottle formula.

Monitor the baby for illness or lactose intolerances.

Monitor how often the mother is nursing the infant (infre-quent nursing can cause dehydration and slow weightgain).

Mental Health


If the client is confused or is unable to interpret signs ofthirst, place on intake and output measurement, andrecord this information every shift.

Evaluate potential for fluid deficit resulting from medica-tion or medication interaction (e.g., lithium and diuret-ics). If this presents a risk, place the client on intakeand output measurement every shift.

Evaluate mental status every shift at [times].

If the client’s values and beliefs influence intake:• Alter environment as necessary to facilitate fluid

intake, and note alterations here (e.g., if the clientthinks fluids from cafeteria are poisonous, have theclient assist in making drink on unit).

• Provide positive attention to the client at additionaltimes to avoid not drinking as a way of obtainingnegative attention.

Medications and/or clouded consciousness may affect theclient’s ability to recognize need for fluids.

Estimated daily requirement for adults is 1500 to3000 mL/day.65

Basic monitoring to determine the client’s ability to inde-pendently take fluids.

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized for the aging client.


Encourage the patient to drink at least 8 ounces of fluidevery hour while awake.

Be sure fluids are within reach of the patient confinedto bed.

Older adults may not experience thirst sensation inresponse to fluid deprivation. Older clients may notfeel thirst or dry mouth, even when dehydrated. Whengiven free access to fluids, older adults tend to drinkless than their younger counterparts. Older clients,unprompted, may fail to drink enough fluids to stayadequately hydrated. Thus, frequent offering of fluidsto the older adult is essential.

For those confined to bed or with restricted movement,this action is a simple, basic measure to promote fluidintake.


Fluid Volume, Excess 167

••••••



Assist the client and family in identifying risk factors per-tinent to the situation:

• Diabetes• Protein malnourishment• Extremes of age• Excessive vomiting or diarrhea• Medication for fluid retention or high blood pressure• Confusion or lethargy• Fever• Excessive blood loss• Wound drainage• Inability to obtain adequate fluids because of pain,

immobility, or difficulty in swallowing

Assist the client and family in identifying lifestylechanges that may be required:

• Avoiding excessive use of caffeine, alcohol, laxatives,diuretics, antihistamines, fasting, and high-protein diets

• Using salt tablets• Exercising without electrolyte replacement

Early intervention in risk situations can prevent dehy-dration.

Avoidance of dehydrating activities will prevent excessivefluid loss.

FLUID VOLUME, EXCESS

DEFINITION28

The state in which an individual experiences increased fluidretention and edema.30


1. Jugular vein distention2. Decreased hemoglobin and hematocrit3. Weight gain over short period4. Dyspnea5. Intake exceeds output6. Pleural effusion7. Orthopnea8. S3 heart sounds9. Pulmonary congestion

10. Change in respiratory pattern11. Change in mental status12. Blood pressure changes13. Pulmonary artery pressure changes14. Oliguria15. Specific gravity changes16. Azotemia17. Altered electrolytes18. Restlessness19. Anxiety20. Anasarca21. Abnormal breath sounds, rales (crackles)22. Edema23. Increased central venous pressure24. Positive hepatojugular reflex

RELATED FACTORS28

1. Compromised regulatory mechanisms2. Excess fluid intake3. Excess sodium intake


1. Congestive heart failure2. Renal failure3. Cirrhosis of the liver4. Cancer5. Toxemia


Decreased Cardiac Outputand Impaired Gas ExchangeThe body depends on both appropriate gas exchangeand adequate cardiac output to oxygenate tissuesand circulate nutrients and fluid for use and disposal.If either of these is compromised, then the body willsuffer in some way. One of the major ways the bodysuffers is in the circulation of body fluid. Fluid will beleft in tissue and not absorbed into the general circu-lation to be redistributed or eliminated.

Imbalanced Nutrition, MoreThan Body RequirementsThis diagnosis could be the primary problem. The per-son ingests more food and fluid than the body canmetabolize and eliminate. The result is excess fluidvolume in addition to the other changes in the body’sphysiology.





Urinary RetentionOne way the body compensates fluid balance isthrough urinary elimination. If the body cannot prop-erly eliminate fluids, then the system “backs up” so tospeak, and excess fluid remains in the tissues.

Impaired Physical MobilityBesides appropriate gas exchange and adequate car-diac output, the body also needs movement of mus-cles to assist in transporting food and fluids to andfrom the tissue. Impaired Physical Mobility might leadto an alteration in movement of food and fluids. Wasteproducts of metabolism and excess fluid are allowedto remain in tissues, creating a fluid volume excess.


Excess fluid volume can occur as a result of water excess,sodium excess, or water and sodium excess.58 Careful

assessment and monitoring is needed to recognize the dif-ference in precipitating causes.

Edema: Mild or 1� means that the skin can bedepressed 0 to 1/4 inch; moderate or 2� means that the skincan be depressed 1/4 to 1/2 inch; severe or 3� means that theskin can be depressed 1/2 to 1 inch; and deep pitting edemaor 4� means that the skin can be depressed more than 1 inchand it takes longer than 30 seconds to rebound.

EXPECTED OUTCOME

Intake and output will balance within 200 mL by [date].

● N O T E : May want difference to be only 50 mL for achild.

TARGET DATES

In a healthy person, intake and output reach an approximatebalance over a span of 72 hours. An acceptable target datewould then logically be the third day after admission.


••••••


Adult Health


Take vital signs every 2 hours at [state times here], andinclude apical pulse.

Check lung, heart, and breath sounds every 2 hours on[odd/even] hour.

Elevate head of bed 30 degrees if not contraindicated.

Check intake and output hourly (urinary output not lessthan 30 milliliters/hour).

Measure and record total intake and output every shift.

Observe and document quantity and character of urine,vomitus, and stools.

Check urine specific gravity at least every 2 hours on[odd/even] hour.

Monitor:• Skin turgor at least every 4 hours while awake. [Note

times here.]• Electrolytes, hemoglobin, and hematocrit. Collaborate

with health-care team regarding frequency of labora-tory tests.

• Mental status and behavior at least every 2 hours on[odd/even] hour.

Weigh daily at [state times here]. Weigh at same timeeach day and in same-weight clothing.

Administer medication (e.g., diuretics) as prescribed.Monitor medication effects.

Collaborate with health-care provider to develop fluidrestriction regimen clearly indicating amount per shift.

Permits monitoring of cardiovascular response to illnessstate and therapy.

Essential monitoring for fluid collection in lungs and car-diac overload due to edema.

Facilitates respiration.

Determines extent of fluid balance, need for diuresis, orprogress of therapy.

Essential monitoring for fluid and electrolyte imbalance.

Monitoring for fluid replacement. Allows consistent com-parison of weight.

Restricting fluids prevents cardiovascular system overloadand potential pulmonary effects.



••••••


Teach the patient to monitor his or her own intake andoutput at home.

In collaboration with dietitian:• Obtain nutritional history.

Refer to other health-care professionals, as appropriate.

Supports the patient’s self-care by pointing out measureshe or she can use to control fluid imbalance. Adequateintake and early intervention will prevent undesirableoutcomes.

Cost-effective use of readily available resources. Pro-motes interdisciplinary care and thus better care forthe patient.

Child Health


Measure and record total intake, output, blood pressure,and pulse every shift:

• Check intake and output hourly, and weigh diapers.• Monitor specific gravity at least every 2 hours or as

specified.Reposition as tolerated every half-hour.

Weigh daily at the same time under the same conditionsof dress (infants without clothes, children in under-wear).

Administer medications as ordered with attention toappropriate dosage and potential effect on electrolytes.

Anticipate potential for respiratory distress and monitorappropriately by cautious checking of breath sounds,respiratory effort, and level of consciousness.

Administer fluids per IV with appropriate equipment; i.e.,when using Buretrol clamp off main supply of fluidseven while on IV pump. Place enough fluid for 2 hoursat a time in the Buretrol, and use medium infusionpumps for medications. In young infants, 1 hour offluid may be used.

A strict assessment of intake and output serves to guidetreatment for indication of hydration status. The spe-cific gravity assists in determining cardiac, renal, andrespiratory function and electrolyte status.

Prevents stasis of fluids in any one part of body. Assistsin circulation of fluid and in preventing skin integrityproblems.

Accuracy of weight is critical; it serves as a major indica-tor for treatment effectiveness, and is an ongoingparameter for treatment.

Potassium and sodium alterations may be present andmust be addressed to prevent further fluid or electrolyteimbalance.

Fluid overload and fluid and electrolyte deviations maylead to respiratory and/or cardiac arrest if undetectedor untreated.

Likelihood of iatrogenic fluid overdose is lessened withappropriate safeguards.

Women’s Health

● N O T E : Pregnancy-induced hypertension (PIH), often called the “disease oftheories,” has been documented for the last 200 years. Numerous causes havebeen proposed but never substantiated; however, data collected during this timedo support the following:

1. Chorionic villi must be present in the uterus for a diagnosis of PIH to be made.2. Women exposed for the first time to chorionic villi are at increased risk for developing PIH.3. Women exposed to an increased amount of chorionic villi (e.g., multiple gestation or hydatidiform mole) are at greater

risk for developing PIH.4. Women with a history of PIH in a previous pregnancy are at increased risk for developing PIH.5. Women who change partners are more likely to develop PIH in a subsequent pregnancy.6. There is a genetic predisposition for the development of PIH, which may be a single gene or multifactorial.7. Vascular disease places the patient at greater risk for developing superimposed PIH.64




••••••


Women’s Health


Review the client’s history for factors associated withpregnancy-induced hypertension (PIH):

• Family and personal history such as diabetes or multi-ple gestation

• Rh incompatibility or hypertensive disorder• Chronic blood pressure 140/90 mm Hg or greater prior

to pregnancy, or in the absence of a hydatidiform mole,that persists for 42 days postpartum

During current pregnancy, observe for the following char-acteristics of PIH:

• Nulliparous women younger than 20 or older than 35years of age

• Multipara with multiple gestation or renal or vasculardisease

• Presence of hydatidiform mole

Monitor the patient for chronic hypertension65:• Increase in systolic blood pressure of 30 mm Hg or

diastolic blood pressure of at least 15 mm Hg abovebaseline on two occasions at least 2 hours apart

• Development of proteinuria

Monitor and teach the patient to immediately report thefollowing signs of PIH:

• Increase of 30 mm Hg in blood pressure or 140/90blood pressure and above

• Edema: Weight gain of 5 pounds or greater in 1 week• Proteinuria: 1 g/L or greater of protein in a 24-hour

urine collection (2� by dipstick)• Visual disturbances: blurring of vision or headaches• Epigastric pain

Observe closely for signs of severe preeclampsia in anypatient who presents with64:

• Blood pressure greater than or equal to 160 mm Hgsystolic, or greater than or equal to 110 mm Hg dias-tolic, on at least two occasions 6 hours apart with thepatient on bedrest

• Proteinuria greater than or equal to 5 g in 24 hours or3� to 4� on qualitative assessment

• Oliguria: less than 400 mL in 24 hours• Cerebral or visual disturbances• Epigastric pain• Pulmonary edema or cyanosis• Impaired liver function of unclear etiology• Thrombocytopenia

Monitor, at least once per shift, for edema. Teach thepatient to:

• Monitor swelling of hands, face, legs, or feet.(Caution: May need to remove rings.)

• Be aware of a possible need to wear loose shoes or abigger shoe size.

Basic database required to assess for potential of PIH.

Increased knowledge for the patient will assist the patientwith earlier help-seeking behaviors.

Increased knowledge for the patient will assist the patientwith earlier help-seeking behaviors.

Knowledge of the complexity and multisystem nature ofthe disease assists with early detection and treatment.




••••••


• Schedule rest breaks during day and to elevate feet.• When lying down, to lie on left side to promote placen-

tal perfusion and prevent compression of vena cava.

In collaboration with the dietitian:• Obtain nutritional history.• Place the patient on high-protein diet (80 to 100 g of

protein).• Place the patient on reduced sodium intake (not more

than 6 g daily or less than 2.5 g daily).

Monitor:• Intake and output: urinary output not less than 30 mL/h

or 120 mL/4 h• Effect of magnesium sulfate (MgSO4) and hydralazine

hydrochloride (Apresoline) therapy (have antidote forMgSO4 [calcium gluconate] available at all times dur-ing MgSO4 therapy)

• Deep tendon reflexes (DTR) at least every 4 hours[state times here]

• Respiratory rate, pulse, and blood pressure at leastevery 2 hours on the [odd/even] hour

• Fetal heart rate and well-being at least every 2 hours onthe [odd/even] hour

Institute seizure precautions.

Ensure bedrest and reduction of noise level in thepatient’s environment.

Decreases sensory stimuli that might increase the likeli-hood of a seizure.

Mental Health


Observe chronic psychiatric clients and clients with pre-existing alcoholism66 for signs and symptoms of poly-dipsia and/or water intoxication. The observationsinclude66–68:

• Frequent trips to sources of fluid and excessive con-sumption of fluids

• Client stating, “I feel as if I have to drink water all ofthe time,” or a similar statement

• Fluid-seeking behavior• Dramatic or rapid fluctuations in weight• Polyuria• Incontinence• Carrying large cups• Urine specific gravity of 1.008 or less66

• Decreases in serum sodiumDiscuss the client’s explanations for excessive drinking to

determine causes of excessive fluid intake. If it is deter-mined that drinking is a diversionary activity or anattempt to avoid interaction, implement nursing actionsfor Social Isolation and/or Deficient DiversionalActivity, as appropriate. If it is determined that fluidintake is related to testing concern of staff or testinglimits, refer to nursing actions for Powerlessness orSelf-Esteem disturbances.

A pattern of extreme polydipsia and polyuria can developin clients with psychiatric disorders. This may berelated to dopamine central nervous system activityand dysfunction in antidiuretic hormone activity incombination with psychosocial factors. The sense ofthirst can also be increased by certain medications.67,68

Determining exact reason for polydipsia allows for moreeffective intervention.




••••••


Mental Health


If it is determined that the client is at risk for water intox-ication, implement the following actions:

• Monitor and document fluid intake and output andweight fluctuations on a daily basis.

• Restrict fluids as ordered by physician.

Provide small medicine cup (30 mL) for the client toobtain fluids.

Provide fluids such as chipped ice on a schedule. [Noteschedule here.]

Instruct the client in need for reducing nicotine consump-tion. If the client cannot do this, it may be necessary toinitiate a “rationing” plan. If so, note plan here.

Provide the client with sugarless gum and/or hard candyto decrease dry mouth. [Note the client’s preference.]

Identify with the client those activities that would bemost helpful in diverting attention from fluid restric-tion. [Note specific activities here with schedule foruse.]

Refer to occupational and recreational therapists.

If the client continues to have difficulty restricting fluids,provide increased supervision by limiting the client today area or other group activity rooms where he or shecan be observed. Note restrictions here. If necessary,place the client on one-to-one observation.

Talk with the client about feelings engendered by restric-tions for 15 minutes per shift. [Note times here.]

Discuss the client’s restriction in a community meeting if:• Restrictions are impacting others on the unit.• Support from peers would facilitate client’s maintain-

ing restrictions.

Provide positive verbal support for the client’s maintain-ing restriction(s).

Identify with the client appropriate rewards for maintain-ing restrictions and reaching goals. Describe rewardsand behaviors necessary to obtain rewards here.

Water intoxication can be life-threatening.66

Nicotine increases release of antidiuretic hormone(ADH), a water-conserving hormone.66

Promotes the client’s self-esteem and provides motivationfor continued efforts.

Promotes the client’s self-esteem and sense of control andprovides motivation for continuing his or her efforts.

Gerontic Health

Nursing actions for the gerontic health patient with this nursing diagnosis are the same as those for Adult Health and HomeHealth.



Teach methods to protect edematous tissue: Tissue is at risk for injury. The client and family can betaught to minimize risks and damage.


FLUID VOLUME, IMBALANCED,RISK FOR

DEFINITION28

A risk of a decrease, increase, or rapid shift from one to theother of intravascular, interstitial, and/or intracellular fluid.This refers to the loss or excess or both of body fluids orreplacement fluids.


None given.

RISK FACTORS28

1. Scheduled for major invasive procedures2. Other risk factors to be determined


1. Any major surgical procedure2. Any kidney or adrenal gland disease3. Hemorrhage4. Burns5. Any disease impacting the intestines


Risk for Deficient Fluid VolumeThis diagnosis refers to the danger of fluid loss,whereas Risk for Imbalanced Fluid Volume can beeither a deficit or an excess. Risk for Fluid VolumeImbalance should be used until the nurse can defini-tively evaluate in which direction the fluid shift is going.

Fluid Volume, Imbalanced, Risk For 173

••••••


• Practice proper body alignment.• Use pillows, pads, etc. to relieve pressure on dependent

parts.• Avoid shearing force when moving in bed or chair.• Alter position at least every 2 hours.

Assist the client and family to set criteria to help themdetermine when a physician or other intervention isrequired.

Assist the client and family in identifying risk factors per-tinent to the situation (e.g., heart disease, kidney dis-ease, diabetes mellitus, diabetes insipidus, liverdisease, pregnancy, or immobility).

Teach signs and symptoms of fluid excess:• Peripheral and dependent edema• Shortness of breath• Taut and shiny skin


• Avoid standing or sitting for long periods of time; ele-vate edematous limbs.

• Avoid crossing legs.• Avoid constrictive clothing (girdles, garters, knee-high

stockings, rubber bands to hold up stocking, etc.).• Consider wearing antiembolism stockings.• Avoid excess salt. Teach the patient and family to read

labels for sodium content. Avoid canned and fast foods.• Use spices other than salt in cooking.• Avoid lying in one position for longer than 2 hours.• Raise head of bed or sit in chair if having difficulty

breathing.• Restriction of fluid intake as necessary (e.g., usual in

kidney and liver disease).• Weigh at the same time every day wearing the same

clothes and using the same scale.Teach purposes and side effects of medication (e.g.,

diuretics or cardiac medications).

Planned decision making to prepare for potential crisis.

Identification of risk factors and understanding of rela-tionship to fluid excess provide for intervention toreduce or prevent negative outcomes.

Early recognition of signs and symptoms provides datafor early intervention.

Knowledge and support provide motivation for changeand increase potential for positive outcome.

Appropriate use of medication and reduction of sideeffects.





Excess Fluid VolumeThis is an actual diagnosis and signifies a fluid over-load.

EXPECTED OUTCOME

Will not exhibit any signs or symptoms of deficient fluidvolume or excess fluid volume by [date].

Will have a 24-hour balance in intake and output offluids by [date].

TARGET DATES

In a healthy person, intake and output reach an approxi-mate balance over a span of 72 hours. An acceptable tar-get date would then logically be the third day afteradmission.


••••••


Adult Health


Measure and record total intake and output every shift.

Check intake and output hourly.

Check urine specific gravity every 4 hours at [state timeshere].

Observe and document color and character of all urine,stools, and vomitus.

Take vital signs every 2 hours on [odd/even] hour andinclude apical pulse.

Check lung, heart, and breath sounds every 2 hours on[odd/even] hour.

Elevate head of bed as needed.

Monitor:• Weight: Weigh daily at [state time here]. Teach the

patient to weigh at same time each day in same-weightclothing.

• Skin turgor at least every 4 hours at [state times here]while awake

• Electrolytes, blood urea nitrogen, hematocrit, andhemoglobin (Collaborate with physician regarding fre-quency of laboratory tests.)

• Central venous pressure every hour (if appropriate)• Mental status and behavior at least every 2 hours on

[odd/even] hour• For signs and symptoms of shock at least once per hour

(e.g., weakness, diaphoresis, hypotension, tachycardiaor tachypnea)

If evidence suggests a fluid volume deficit, see actions forFluid Volume Deficit, Actual.

If evidence suggests a fluid volume excess, see actionsfor Fluid Volume Excess, Actual.

Determines fluid loss or fluid retention and need forreplacement or restriction of fluids.

Permits monitoring of cardiovascular response to illnessstate and therapy.

Facilitates respiration.

Essential monitoring for fluid and electrolyte balance.Monitoring for fluid replacement. Allows consistent

comparison of weight.

Essential monitoring for intravascular fluid volumebalance.

Restricting fluids prevents cardiovascular system overloadand reduces workload.


Fluid Volume, Imbalanced, Risk For 175

••••••

Child Health


Monitor at-risk populations, especially those infants andchildren scheduled for surgery or procedures in whichNPO status is necessary for fluid inbalances.

Determine preoperatively or prior to onset of proceduresthe ongoing fluid plan for the client with specificationsfor:

• Type of fluid and status of oral feedings• Rate of administration of IV fluid• Electrolyte status and additives to be administered• Accurate weight• Accurate 24-hour intake and output• Recent essential preoperative laboratory tests with

abnormal results addressed• Allowance for special drainage or physiologic demands• Past 24-hour specific gravity record

Identify appropriate parameters to be addressed by allmembers of the health-care team during and after sur-gery or procedure to include cardiac, renal, neurologic,metabolic, and related physiologic alterations.

Maintain the patient’s temperature during and after sur-gery or procedure.

Greater likelihood exists for fluid volume imbalanceswith infants or children who undergo surgery duringwhich fluids may be lost or gained in a short periodof time.

Anticipatory planning provides appropriate focus on riskfor deficit or overload for vulnerable infants and chil-dren in advance of actual occurrence.

Pre-identification of coordination of multidisciplinaryspecialists assists in appropriate fluid maintenance.

Metabolic demands are lessened in the absence of coldstress or hyperthermia.

Women’s Health

● N O T E : Bleeding can occur rapidly during pregnancy, delivery, and postpartum.There is potential for maternal exsanguination within 8 to 10 minutes because of thelarge amount of blood flowing to the uterus and placenta during pregnancy.


Monitor the patients presenting to labor and delivery forsigns and symptoms of:

• Severe abruptio-persistent uterine contractions• Shock out of proportion to blood loss• Rigid, tender, localized uterine pain, and tetanic con-

tractions• Bright red bleeding without pain

Carefully monitor for uterine involution and signs andsymptoms of bleeding during delivery and postpartum.

Abruptio placentae accounts for approximately 15 per-cent of all perinatal deaths.

Placenta previa occurs in 0.005 percent of pregnanciesbut has a reoccurrence rate of 4 to 8 percent.

Subinvolution, retained products of conception, uterineatony, and lacerations of the birth canal are the leadingcauses of postpartum hemorrhage.

Mental Health

The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health.(care plan continued on page 176)


HYPERTHERMIA

DEFINITION28

A state in which an individual’s body temperature is ele-vated above his or her normal range.


1. Increase in body temperature above normal range2. Seizures or convulsion3. Flushed skin4. Increased respiratory rate5. Tachycardia6. Warm to touch

RELATED FACTORS28

1. Illness or trauma2. Increased metabolic rate3. Vigorous activity4. Medications or anesthesia5. Inability or decreased ability to perspire6. Exposure to hot environment7. Dehydration8. Inappropriate clothing


1. Any infectious process2. Septicemia


••••••


Gerontic Health

● N O T E : See interventions for Adult Health. Older adults are at risk for this diagnosisas a result of aging changes that affect the ability to respond to volume changes. Renalsystem changes make responses to volume overload or depletion difficult. Older adultsexperience a delayed response to a decrease in sodium and are at higher risk for volumedepletion. A delay in the ability to excrete salt and water leads to an increased risk forfluid overload and hyponatremia. Postoperatively, the older adult may have excessive orprolonged aldosterone/ADH responses, causing difficulty eliminating excess fluids.



Monitor the client for the presence of ascites (e.g.,abdominal distention with weight gain) or edema, andreport to physician.

Monitor for signs of dehydration:• Dry tongue and skin• Sunken eyeballs• Muscle weakness• Decreased urinary output

Educate the client and caregivers about the importance ofadhering to a sodium-restricted diet (e.g., 250 to 500mg per day).

Educate the client and caregivers about medications pre-scribed to control the fluid volume imbalance (e.g.,potassium-sparing diuretics) and possible side effects.

Assist the client in obtaining supplies necessary to meas-ure intake and output, and teach the client and care-givers how to measure and record intake and output.

Monitor balance each nursing visit.

Prevents complications of fluid shifts.

Dehydration may accompany fluid shifts such as ascitesor edema.

Promotes normal fluid balance.

Promotes compliance with prescribed medications.

Basic monitoring for imbalances.

Allows for early identification of progressing fluidimbalances.


Hyperthermia 177

••••••

3. Hyperthyroidism4. Any disease leading to dehydration (e.g., diarrhea, vom-

iting, hemorrhage)5. Any condition causing pressure on the brainstem6. Heat stroke


Risk for Imbalanced Body TemperatureThis diagnosis indicates that the person is potentiallyunable to regulate heat production and dissipationwithin a normal range. In Hyperthermia, the patient’sability to produce heat is not impaired. Heat dissipationis impaired to the degree that Hyperthermia results.

Ineffective ThermoregulationIneffective Thermoregulation indicates that thepatient’s body temperature is fluctuating betweenbeing elevated and being subnormal. In Hyperthermia,the temperature does not fluctuate; it remains elevateduntil the underlying cause of the elevation is negated

or until administration of medications such as Tylenoland aspirin show a definitive effect on the elevation.

HypothermiaHypothermia means the patient’s body temperature issubnormal. This indicates the exact opposite meas-urement from Hyperthermia.

EXPECTED OUTCOME

Will return to normal body temperature (range between 97.3and 98.8�F) by [date].

TARGET DATES

Because hyperthermia can be life-threatening, initial targetdates should be in terms of hours. After the patient hasdemonstrated some stability toward a normal range, the tar-get date can be increased to 2 to 4 days.


Adult Health


Monitor temperature every [odd/even] hour while thepatient is awake and temperature remains elevated.Measure temperature every 2 hours during night. [Notetimes here.] After temperature begins to decrease,lengthen time between temperature measurements.

Implement strategies to decrease temperature includingsponging the patient with cool water, applying continu-ous cold packs, providing a tepid bath, or use of acooling blanket until temperature is lowered to at least102�F. Dry the patient well, and keep dry and clean.

Use a fan to cool environment to no less than 70�F.Give antipyretic drugs as prescribed. Closely monitor

effects, and document effects within 30 minutes aftermedications given.

Maintain seizure precautions until temperature stabilizes.

Monitor intake and output, and daily weights.Give skin, mouth, and nasal care at least every 4 hours

while awake. [Note times here.]

Change bed linens and pajamas as often as necessary.

Do not give stimulants.

Gather data relevant to underlying contributing factors atleast once per shift.

Hyperthermia is incompatible with cellular life.

Basic measures to assist in temperature reduction via heatdissipation. Overchilling could cause shivering, whichincreases heat production.

Promotes cooling via heat dissipation.Antipyretics assist in temperature reduction. Allows the

health-care team to assess the effectiveness of theantipyretic. Ineffectiveness would require repeatingmedication or changing to a different antipyretic.

Hyperthermia can lead to febrile seizures as a result ofoverstimulation of the nervous system.

To avoid fluid volume deficits.Hyperthermia promotes mouth breathing in an effort to

dissipate heat. Mouth breathing dries the oral mucousmembrane.

Keeping bed linens and pajamas dry helps avoid shiver-ing.

Stimulants cause vasoconstriction, which could increasehyperthermia.

Control of underlying factors helps prevent occurrence ofhyperthermia.




••••••


Adult Health


Provide health-care teaching, beginning on admission,regarding:

• Need for frequent temperature checks• Related medical or nursing care• Safety needs when using ice packs or electric cooling

blanket• How family can assist in care• Importance of hydration• Possible fear or altered comfort of patient with fever

because of discomfort, fast heart rate, dizziness, andgeneral feeling of illness

• Possible seizure activity

Carry out appropriate infection control process, in theevent or potential event of infectious disease, accordingto actual or suspected organisms.

Assist in obtaining specimens for culture.

Assist in promoting a quiet environment.

Relieves anxiety and allows the patient and family to par-ticipate in care. Initiates home care planning.

Prevents spread of infection.

Assists in identifying potential causative source.

Allows for essential sleep and rest.Hyperthermia causes increased metabolic rate.

Child Health


Monitor temperature every 30 minutes until temperaturestabilizes.

• In malignant hyperthermia secondary to response toanesthetic agent such as halothane, prevention includespre-operative assessment for family history, but risk isstill present with each successive surgery.

Administer antipyretic, antiseizure, or antibiotic medica-tions as ordered with precaution for:

• In diagnosed malignant hyperthermia, dantrolene orsimilar agent will be given.

• Maintenance of IV line• Drug safe range for the child’s age and weight• Potential untoward response• IV compatibility• The infant’s or child’s renal, hepatic, GI status and risk

for cardiac arrhythmias secondary to tachycardia

Provide padding to siderails of crib or bed to preventinjury in event of possible seizures.

Ensure that airway maintenance is addressed by appropri-ate suctioning and airway equipment according to age.

During acute phase of treatment, as applicable, recogniz-ing need for cooling blanket, gastric lavage, and possi-ble cardiopulmonary bypass, assist in explainingprocedures to family and provide updates on child’sstatus on a regular basis.

Frequent assessment per tympanic (aural) thermometer oras specified provides cues to evaluate efficacy of treat-ment and monitors underlying pathology.

Unique components for each individual patient must beconsidered within usual treatment modalities to helpbring safe and timely return of temperature whileavoiding iatrogenic complications.

Protection from injury in likelihood of uncontrolled sud-den bodily movement serves to protect the patient fromfurther problems. Uses universal seizure precautions.

As a part of seizure activity, there is always the potentialof loss of consciousness with respiratory involvement.

Regular and timely informative updates alleviate fearsand assist family in coping.


Hyperthermia 179

••••••

Women’s Health

● N O T E : Women’s Health will have the same nursing actions and rationales as AdultHealth, Gerontic Health, and Psychiatric Health, except for the following: (Newborn isincluded with Women’s Health because newborn care is administered by nurses inmother-baby units.)


When under heat source or bililights, monitor the infantevery hour for increased redness and sweating. Checkheat source at least every 30 minutes (overhead, iso-lettes, or bililights).

Monitor the infant’s temperature, skin turgor, andfontanels (bulging or sunken) for signs and symptomsof dehydration every 30 minutes while under heatsource. First temperature measurement should be rec-tal; thereafter can be axillary.

Check for urination; the infant should wet at least six dia-pers every 24 hours.

Replace lost fluids by offering the infant breast, water, orformula at least every 2 hours on [odd/even] hour.

Pregnancy:• Teach the patient to avoid use of hot tubs or saunas.

• During first trimester: Concerns about possible CNSdefects in fetus and failure of neural tube closure.69

• During second and third trimesters: Concerns aboutcardiac load for mother.69

• Provide cooling fans for mothers during labor and forpatients on MgSO4 therapy.

• Keep the labor room cool for the mother’s comfort.

Provides safe environment for the infant.

Provides essential information as to the infant’s currentstatus and promotes a safe environment for the infant.

Basic monitoring of the infant’s physiologic functioning.

Decreases insensible fluid loss and maintains body tem-perature within normal range. This action decreases theinfant’s needs for IV glucose.

Provides safe environment for the mother and preventsinjury to the fetus.

Mental Health

Adult Health plan of care provides the foundation care of the mental health client with the following considerations:


Monitor clients receiving neuroleptic drugs for decreasedability to sweat by observing for decreased perspirationand an increase in body temperature with activity,especially in warm weather. Monitor these clients forhyperpyrexia (up to 107�F). Notify physician of alter-ations in temperature. Note alteration in the client’splan of care and initiate the following actions:

• The client should not go outside in the warmest part ofthe day during warm weather.

• Maintain the client’s fluid intake up to 3000 mL every24 hours by (this is especially important for clientswho are also receiving lithium carbonate; lithium levelsshould be carefully evaluated):• Having client’s favorite fluids on the unit.• Having the client drink 240 mL (8-ounce) glass of

fluids every hour while awake, and 240 mL with eachmeal. If necessary, the nurse will sit with the clientwhile the fluid is consumed.

Clients who are receiving neuroleptic medications are atrisk for developing neuroleptic malignant syndrome,which can be life-threatening.65




••••••


Mental Health


• Maintaining record of the client’s intake and output.• Dress the client in light, loose clothing.• If the client is disoriented or confused, provide one-to-

one observation.

Decrease the client’s activity level by:• Decreasing stimuli• Sitting with the client and talking quietly, or involving

the client in a table game or activity that requires littlelarge muscle movement. [Note activities that that clientenjoys here.]

• Assigning room near nurse’s station and dayroom areas

Monitor the client’s mental status every hour.

Do not provide clients with alteration in mental statuswith small electrical cooling devices unless theyreceive constant supervision.

Give the client as much information as possible about hisor her condition and measures that are implemented todecrease temperature.

Teach the client and family measures to decrease or elim-inate risk for hyperthermia. (See Home Health forteaching information.)


High fevers can alter mental status and thus decrease theclient’s ability to make proper judgments.

Increased physical activity increases body temperature,and the decreased ability to sweat, secondary to med-ications, inhibits the body’s normal adaptiveresponse.65

Gerontic Health

● N O T E : Normal changes of aging may alter the older client’s experience of hyperther-mia. Older clients may exhibit diminished sweating and a diminished sensory perceptionof heat. Thus, careful assessment is essential in older clients.



Facilitate the client’s maintenance of adequate hydration,especially during periods of infection, activity, or heat.

Teach the client symptoms of heat cramps:• Painful musculoskeletal cramps and spasms• Tender muscles• Moist skin• Normal or slightly elevated body temperature

For clients with heat cramps, provide oral saline solution,and rest in a cool place.

Teach the client symptoms of heat syncope:• Sudden episode of unconsciousness• Weak pulse• Cool and moist skin

For clients with heat syncope, place the client in a recum-bent position, provide oral or IV fluids, and allow forrest in a cool place.

Primary prevention.

Allows for early recognition and prevents complications.

Prevents complications.




Hyperthermia 181

••••••


Teach clients symptoms of heat exhaustion:• Thirst• Fatigue• Nausea• Reduced urine output• Giddiness or delirium

For clients with heat exhaustion, allow for rest in a coolenvironment, and replace fluids with saline solution(oral or IV).

Teach clients/caregivers signs of heat stroke:• Absence of sweating• Loss of consciousness

For clients with heat stroke, access emergency servicesimmediately, remove excess clothing, and cool theclient rapidly (cold water immersion, ice packs, tepidwater spray, fans) without inducing shivering.



Signifies the need for emergency interventions.

Prevents further complications.



Monitor for factors contributing to hyperthermia. (SeeDefining Characteristics.)

Teach the client and family signs and symptoms of hyper-thermia:

• Flushed skin• Increased respiratory rate• Increased heart rate• Increase in body temperature• Seizure precautions and care

Teach measures to decrease or eliminate the risk ofhyperthermia:

• Wearing appropriate clothing• Taking appropriate care of underlying disease• Avoiding exposure to hot environments• Preventing dehydration• Using antipyretics• Performing early intervention with gradual cooling

Involve the client and family in planning, implementing,and promoting reduction or elimination of the risk forhyperthermia.


• Measure temperature using appropriate method fordevelopmental age of person.

• Learn survival techniques if the client works or playsoutdoors.

• Ensure proper hydration.• Transport to health-care facility.• Use emergency transport system.

Identification of risk factors provides for intervention toreduce or prevent negative outcomes.

Provides data for early intervention.

Provides basic knowledge that increases the probabilityof successful self-care.

Involvement provides opportunity for increased motiva-tion and ability to appropriately intervene.

Knowledge and support provide motivation for changeand increase potential for a positive outcome.


HYPOTHERMIA

DEFINITION28

The state in which an individual’s body temperature isreduced below normal range.28


1. Pallor (moderate)2. Reduction in body temperature below normal

range3. Shivering (mild)4. Cool skin5. Cyanotic nail beds6. Hypertension7. Piloerection8. Slow capillary refill9. Tachycardia

RELATED FACTORS28

1. Exposure to cool or cold environment2. Medications causing vasodilation3. Malnutrition4. Inadequate clothing5. Illness or trauma6. Evaporation from skin in cool environ-

ment7. Decreased metabolic rate8. Damage to hypothalamus9. Consumption of alcohol

10. Aging11. Inability or decreased ability to shiver12. Inactivity


1. Hypothyroidism2. Anorexia nervosa3. Any injury to the brainstem


Risk for Imbalanced Body TemperatureThis diagnosis indicates that the person is potentiallyunable to regulate heat production and heat dissipa-tion within a normal range. In Hypothermia, thepatient’s ability to dissipate heat is not impaired. Heatproduction is impaired to the degree that Hypothermiaresults.

Ineffective ThermoregulationThe body temperature fluctuates between being toohigh and too low. In Hypothermia, the temperaturedoes not fluctuate; it remains low.

HyperthermiaThe patient’s temperature is above normal, not belownormal.

EXPECTED OUTCOME

Will identify at least [number] measures to use in correctinghypothermia by [date]

Body temperature and vital signs will be within nor-mal limits by [date].

TARGET DATES

Hypothermia can be life-threatening; therefore, initial targetdates should be in terms of hours. After the patient hasdemonstrated some stability toward a normal range, targetdates can be increased to 2 to 4 days.


••••••


Adult Health


Monitor temperature measurement every hour until tem-perature returns to normal levels and stabilizes.

Warm the patient quickly. Increase room temperature.Use warming blankets and warmed IV fluids; closedoors to room.

Prevent injury. Gently massage body; however, do not ruba body part if frostbite is evident.

Assesses effectiveness of therapy.

Basic measures that assist in increasing core temperatureand prevent excess heat dissipation. Heat lamps andhot-water bottles warm only a limited area and increasethe likelihood of local tissue damage.

Massage helps stimulate circulation; however, massage ofa frostbitten area promotes tissue death and gangrene.In frostbite, circulation has to be gradually reestab-lished through warming.


Hypothermia 183

••••••


Address skin protective needs by frequent monitoring forbreakdown or altered circulation.

Monitor respiratory rate, depth, and breath sounds everyhour. Provide for airway suctioning and positioning asneeded.

Bathe with appropriate protection and covering.Devote appropriate attention to prevention of major com-

plications such as shock, cardiac failure, tissue necro-sis, infection, fluid and electrolyte imbalance,convulsions or loss of consciousness, respiratory fail-ure, and renal failure.

Administer medications as prescribed.Monitor effects of medication, and record within 30 min-

utes after administration.Obtain a detailed history regarding:• Onset• Related trauma and causative factors• Duration of hypothermia

Provide opportunities for the patient and family to askquestions and relay concerns by including 30 minutesfor this every shift. [Note times here.]

Allow for appropriate attention to resolution of psycho-logical trauma, especially in instances of severe expo-sure to cold at least once per shift. [Note times here.]

Teach the patient and family measures to decrease oreliminate the risk for hypothermia, to include:

• Wearing appropriate clothing when outdoors• Maintaining room temperature at minimum of 65�F• Wearing clothing in layers• Covering the head, hands, and feet when outdoors

(especially the head)• Removing wet clothing

Teach the patient about the kinds of behavior thatincrease the risk for hypothermia:

• Drug and alcohol abuse• Working, living, or playing outdoors• Poor nutrition, especially when body fat is reduced

below normal levels as in anorexia nervosaTeach the patient and family signs and symptoms of early

hypothermia:• Confusion, disorientation• Slurred speech• Low blood pressure• Difficulty in awakening• Weak pulse• Cold stomach• Impaired coordination

Make appropriate arrangements for follow-up after dis-charge from hospital. Identify support groups in thecommunity for the patient and family.

Consult with appropriate assistive resources as indicated:

Hypothermia causes peripheral vasoconstriction, whichleads to a risk for impaired skin integrity.

Hypothermia and its related factors promote the develop-ment of respiratory complications.

Prevents heat loss.Awareness of the complications of hypothermia will help

prevent the complication.

Assists in monitoring effectiveness of therapy.

Decreases anxiety and facilitates home care teaching.

Helps in reducing patient’s anxiety, and facilitatespatient’s resolving lingering effects of trauma.

Permits the patient to participate in self-care, and pro-motes compliance to prevent future episodes.

Fosters resources for long-term management in terms ofadequate housing, financial resources, and socialhabits.

Promotes effective long-term management and preventionof future episode.




••••••


Adult Health


• Obtain an energy audit by public service company toidentify possible sources of heat loss.

• Refer the patient to social services to provide informa-tion on emergency shelters, clothing, and food banks.

• Recommend financial counseling if heating the home isfinancially difficult.

Child Health


Monitor for level of involvement according to history andcontributing factors, and address client’s initial stabi-lization as appropriate.

• During the immediate treatment phase, the infant orchild may require intensive care to include assistedventilation and cardiac and renal monitoring as stabi-lization is achieved.

Provide for maintenance of body temperature by hat(stockinette for infant) and using open radiant warmer,isolette, or heating blanket.

Incorporate other health-care team members to addresscollaborative needs.

Monitor for knowledge needs and provide teaching toaddress unknown and necessary information for thechild and family in developmentally appropriate terms(e.g., temperature measurement).

Anticipate safety needs according to the patient’s age anddevelopment status. [Note adaptations necessary tomeet safety needs here.]

Teach caregiver(s) preventive measures to decrease likeli-hood of recurrence, especially related to minimizingcold exposure with use of clothing appropriate to theseason such as suitable bunting and snowsuits in coldclimates.

Treatment is determined by level of involvement withanticipatory planning to restore normal homeostasis.

Heat loss is greatest via the head in young infants, as wellas by convection and evaporation. Suitable mainte-nance of temperature by appropriate equipment helpsmaintain neutral body core temperature.

Provision of support for long-term follow-up places valueon the need for care and the importance of compliance.Assists in reducing anxiety.

Serves to establish foundation of trust, and providesessential basis for follow-up care.

Each opportunity for reinforcing the importance of safetyas a part of well-child follow-up should not be over-looked. Emphasize caution with rectal thermometer toprevent trauma to anal sphincter and tissue, and cau-tion the family regarding the use of mercury-glass ther-mometer and breakage. If electronic equipment is used,emphasize the importance of protection to skin, con-stant surveillance, and unique safety needs per manu-facturer.

Assists in ensuring careful consideration of dangers ofcold exposure for infants and children.


Hypothermia 185

••••••

Women’s Health

Newborn

● N O T E : This nursing diagnosis pertains to the woman the same as to any other man.The reader is referred to the other sections for specific nursing actions pertaining towomen and hypothermia. Infants control their body temperature with nonshivering ther-mogenesis; this process is accompanied by an increase in oxygen and calorie consump-tion. Therefore, use of a radiant warmer or prewarmed mattress for initial care providesenvironmental heat giving rather than heat losing. However, it is important to note thathypothermia and cold stress in the neonate are related to the amount of oxygen neededby the infant to control apnea and acid–base balance. It is estimated that to replace aheat loss during a temperature drop of 6.3�F, the infant requires a 100 percent increasein oxygen consumption for more than 11/2 hours. Metabolic acidosis can occur quickly ifthe infant becomes hypothermic.5


To prevent hypothermia in the newborn:• Dry the new infant thoroughly.• Cover with blanket.• Lay next to the mother (cover the mother and the infant

by placing the blanket over them).• Place the infant under a radiant heat source.• Keep the infant and mother out of drafts.

Observe the infant for hypothermia. Check temperatureevery hour until stable, then every 4 hours times 4,then once a shift in the hospital. Do not use rectal ther-mometers; take newborn temperatures by axilla or skinprobe (continuous probe).

Prevention of heat loss in the infant reduces oxygen andcalorie consumption and prevents metabolic acidosis.

Skin-to-skin contact with the mother is absolutely thebest method of producing and maintaining the infant’sthermal balance.

Mental Health


Monitor the client’s mental status every 2 hours [notetimes here]; report alterations to the physician.

If the client is receiving antipsychotics or antidepressants,report this to the physician when the alteration is firstnoted.

Protect the client from contact with uncontrolled hotobjects such as space heaters and radiators by teachingclients and family to remove these from the environment.

Allow the client to use heating pads and electric blanketsonly with supervision.

Teach the client the potential for medication to affectbody temperature regulation, especially in the elderly.

Antipsychotic and antidepressant medications can alterthermoregulation, which results in hypothermia.65


Gerontic Health

● N O T E : Aging clients may experience a diminished sensory perception of tempera-tures. Other normal changes of aging such as inefficient vasoconstriction, decreased car-diac output, decreased subcutaneous tissue, and decreased shivering may contribute tothe development of hypothermia in the aging client.



INFANT FEEDING PATTERN,INEFFECTIVE

DEFINITION28

A state in which an infant demonstrates an impaired abilityto suck or coordinate the suck-swallow response.


1. Inability to coordinate sucking, swallowing, and breath-ing

2. Inability to initiate or sustain an effective suck

RELATED FACTORS28

1. Prolonged NPO status2. Anatomic abnormality3. Neurologic impairment or delay4. Oral hypersensitivity5. Prematurity


1. Prematurity2. Cerebral palsy


••••••


Gerontic Health



Teach caregivers to recognize the stages of hypothermia:Early—no feeling of cold, temperature lower than usual

baselineMid—impaired mental functioning, slurred speech,

slowed or irregular pulse, diminished tendon reflexes,slow and shallow respirations

Late—rapid progression of hypothermia, muscular rigid-ity, diminished urinary output, stupor, coma, cool andpink skin

Monitor temperature frequently and regularly.

Use warming blankets with caution.

Utilize warmed IV solutions as appropriate.Utilize cardiac monitoring in high-risk clients.

For late-stage hypothermia, consider core rewarmingtechniques such as cardiac bypass.

Older clients may not verbalize typical symptoms ofhypothermia owing to a decreased sensory perceptionof temperatures. Regular and frequent assessment ofclient status during high-risk times is essential.

Establishes a baseline and allows for early identificationof changes.

Warming blankets may be effective but should be moni-tored closely, as clients may not verbalize or experi-ence possible hyperthermia that may result.

Prevention of complications or further hypothermia.Older clients may experience dysrythmias secondary to

hypothermia.Prevention of further complications.



Involve the client and family in planning, implementing,and promoting reduction or elimination of the risk forhypothermia.


• Avoiding drug and alcohol abuse• Learning survival techniques if the client works or

plays outdoors (e.g., camping, hiking, or skiing)• Keeping the person dry• Transporting to health-care facility• Using emergency transport system

Involvement provides likelihood of increased motivationand ability to intervene appropriately.

Knowledge and support provide motivation for changeand increase the potential for a positive outcome.


Infant Feeding Pattern, Ineffective 187

••••••

Child Health


Monitor for all possible contributory factors:• Actual physiologic sucking potential• Other objective concerns (e.g., swallowing or respira-

tory)• Objective history data (e.g., prematurity or congenital

anomalies)• Maternal or infant reciprocity and degree to which

the mother tunes in to infant’s cues for readinessfor feeding

• Subjective data from the caregivers or parents

Provide anticipatory support to the infant for respira-tory difficulties that could increase the probabilityof aspiration.

Ascertain the most appropriate feeding protocol for theinfant with attention to:

• Nutritional needs according to desired weight gain• Actual feeding mode (i.e., modified nipple, larger hole

nipple, syringe adapted for feeding, position for feed-ing, or gastric tube)

A thorough assessment and monitoring serves as the criti-cal basis for appropriately individualizing and prioritiz-ing a plan of health care.

Airway maintenance is a basic safety precaution for thisinfant. Airway and suctioning equipment are standard.(See nursing actions for Risk for Aspiration.)

A realistic yet holistic approach provides a foundation formultidisciplinary management with best likelihood forsuccess.

Specific criteria provide measurable progress parameters.

3. Thrush4. Hydrocephalus5. Any condition that would require major surgery immedi-

ately after birth


Ineffective BreastfeedingWith this diagnosis, the infant is able to suckle andswallow, but there is dissatisfaction or difficultywith the breastfeeding process. The key differencewould be based on the defining characteristics ofIneffective Breastfeeding versus Ineffective InfantFeeding Pattern. If the infant demonstrates prob-lems with initiating, sustaining, or coordinatingsucking, swallowing, and breathing, then Ineffec-tive Infant Feeding Pattern is the most appropriatediagnosis.

Imbalanced Nutrition, LessThan Body RequirementsCertainly this diagnosis could be the result of IneffectiveInfant Feeding Pattern if the feeding problem is notremedied. However, correction of the primary problemswould prevent the development of this diagnosis.

EXPECTED OUTCOME

Will demonstrate normal ability to suck-swallow by [date].

TARGET DATES

This diagnosis would be life-threatening; therefore, progressshould initially be evaluated every few hours. After the infanthas begun to exhibit at least some sucking-swallowing, thenthe target date can be moved to every 2 days, as improvementis made.


Adult Health

For this diagnosis, Child Health and Women’s Health (Newborn) serve as the generic actions. This diagnosis would notbe used in Adult Health.




••••••


Child Health


• Health status and prognosis• Compliance factors• Socioeconomic factors• Maternal–infant concerns

Explore the feelings the caregivers or parents have relatedto the Ineffective Feeding Pattern.

Strictly monitor and calculate intake, output, and caloriccount on each shift, and total each 24 hours.

Weigh the infant daily or more often as indicated.

Collaborate with other health-care professionals to bettermeet the infant’s needs.

Allow for appropriate time to prepare the infant for feed-ing, and provide a calm, soothing milieu.

Facilitate family to participation in feeding and plans forfeeding.

Provide teaching based on an assessment of parentalknowledge needs and/or deficits. [Note teaching planhere.]

Allow for time to clarify feeding protocols, questions,and discharge planning. Schedule follow-up with lacta-tion specialist as needed.

Often the expression of feelings reduces anxiety and mayallow further potential alterations to be minimized byearly intervention.

Caloric intake and hydration status are indirectly anddirectly used to monitor the infant’s progress in toler-ance of feeding and feeding efficacy.

Weight gain would serve as a major indicator of effectivefeeding and assist in assessment of hydration.

A multidisciplinary approach is most effective in leveland cost of care.

A nonhurried, nonstressful milieu promotes the infant’srelaxation and allows the infant to perceive feeding asa pleasant experience.

Inclusion of the family empowers the family and aug-ments their self-confidence and coping.

Knowledge provides a means of decreasing anxiety.When based on assessed needs, it will reflect the indi-vidualized needs and more likely meet the parents’learning needs.

Appropriate attention to questions and concerns the par-ents may have assists in reducing anxiety, therebyallowing for learning and a greater likelihood of adher-ence to the therapeutic regimen.

Women’s Health


Provide support and information to the mother and signif-icant other. Explain the infant’s inability to suck, andprovide suggestions and options (based on etiology ofsucking problem) to correct or reduce the prob-lem.50,53,70–73

Describe the anatomy and physiology of sucking to themother.

Explain importance of positioning for both bottle- andbreastfeeding.71–73

Provide support and supervision to assist the mother inencouraging the infant to suck properly.

The basic rationale for all the nursing actions in this diag-nosis is to provide nutrition to the infant in the mostappropriate, cost-effective, and successful manner.

Assists in decreasing anxiety, provides a base for teach-ing, and permits long-range planning.

Encourages proper suckling by the infant.


Nausea 189

••••••

Mental Health

This diagnosis would not be used in Mental Health.

Gerontic Health

This diagnosis is not appropriate for the aging patient.


The nursing actions for Home Health would be the same as for Women’s Health.


Assist the mother and family to assess appropriate intakeby observing the infant for at least six to eight wet dia-pers in 24 hours (after milk has come in).

If necessary, provide supplemental nutrition system whileteaching the infant to suck (e.g., dropper, syringe,spoon, cup, or supplementation device).74,75

Refer the mother to lactation consultant or clinical nursespecialist for assistance and support in teaching theinfant to suck.

Assist the mother and significant others to choose feedingsystem for the infant (breast, bottle, cup, or tube) thatwill supply best nutrition.

Ensures that the infant is getting enough nutrition and isnot becoming dehydrated.50,53,71

Pays attention to basic nutrition while also attending toproblem with sucking.

Provides basic support to encourage essential nutrition.

NAUSEA

DEFINITION28

An unpleasant, wave-like sensation in the back of the throat,epigastrium, or throughout the abdomen, that may or maynot lead to vomiting.


1. Reports nausea or “sick to stomach”2. Increased salivation3. Aversion toward food4. Gagging sensation5. Sour taste in mouth6. Increased swallowing

RELATED FACTORS28

1. Treatment related:a. Gastric irritation—pharmaceuticals (e.g., aspirin, non-

steroidal anti-inflammatory drugs, steroids, antibi-otics, alcohol, iron, and blood)

b. Gastric distention—delayed gastric emptying causedby pharmacological interventions (e.g., narcoticsadministration, anesthesia agents)

c. Pharmaceuticals (e.g., analgesics, antivirals for HIV,aspirin, opioids, chemotherapeutic agents)

d. Toxins (e.g., radiotherapy)2. Biophysical

a. Biochemical disorders (e.g., uremia, diabetic ketoaci-dosis, pregnancy)

b. Cardiac painc. Cancer of stomach of intra-abdominal tumors (e.g.,

pelvic or colorectal cancers)d. Esophageal or pancreatic diseasee. Gastric distention due to delayed gastric empty-

ing, pyloric intestinal obstruction, genitourinaryand biliary distention, upper bowel stasis, externalcompression of the stomach, liver, spleen or otherorgan enlargement that slows the stomach function-ing (squashed stomach syndrome), excess foodintake

f. Gastric irritation due to pharyngeal and/or peritonealinflammation

g. Liver or splenetic capsule stretchh. Local tumors (e.g., acoustic neuroma, primary or sec-

ondary brain tumors, bone metastases at the base ofthe skull)

i. Motion sickness, Ménière’s disease, or labyrinthitis


j. Physical factors (e.g., increased intracranial pressure,meningitis)

k. Toxins (e.g., tumor produced peptides, abnormalmetabolites due to cancer)

3. SituationalPsychological factors (e.g., pain, fear, anxiety, noxiousodors, taste, unpleasant visual stimulation)


1. Any surgical procedure2. Cancer3. Any gastrointestinal disease4. Viruses5. Pregnancy


••••••


There really are no other diagnoses that could be con-fused with this diagnosis.

EXPECTED OUTCOME

Will self-report no nausea by [date].

TARGET DATES

Because uncontrolled nausea and vomiting can quickly leadto fluid and electrolyte imbalance, target dates should be at24-hour intervals until the nausea is controlled.


Adult Health


Avoid food smells or unpleasant odors.

Avoid greasy, fatty meals.

Collaborate with the patient and dietitian about food likesand dislikes. [List foods here.]

Try small, frequent feedings. Drink fluids between mealsrather than with meals.

Elevate the head of bed or position on right side for 30minutes after eating if not contraindicated.

Teach diversion, guided imagery, and relaxation.76

Place a cold washcloth over eyes and cheeks.

Collaborate with the health-care provider regarding alter-native treatments.77

Consider alternative therapies such as ginger, peppermint,or cinnamon. [Note use for client here.]

Administer antiemetic medications as prescribed. Monitorfor effects.78–83

Olfactory sense is important in the total dining experience.

Greasy foods promote nausea.

Helps patient feel a part of his or her health-care regimen.

Reduces the amount of food in the stomach and avoidsthe feeling of fullness.

Promotes digestion by gravity.

Reduces stress and takes the mind off the nausea.

Cools the face and diverts blood and attention away fromthe stomach.

Alternative treatments to calm the stomach.

Child Health


Monitor for all possible contributory factors including:• Actual physiologic components (electrolyte imbal-

ances, history of cancer, altered metabolic status,bilirubin elevations, increased intracranial pressure,gastrointestinal irritation/deviations, etc.)

• Potential pharmacologic agents (chemotherapy agents,medications, or allergens)

• Emotional concerns of the client and family or signifi-cant others

• Subjective data from all who have influence in the careof the client

A thorough assessment provides the most appropriatebase of data for individualized care.


Nausea 191

••••••

Gerontic Health



Carefully assess fluid and volume status frequently andregularly.

Consider dietary modifications as appropriate to include:• Small frequent meals• Reduced fat content• Avoidance of indigestible or partially indigestible

materials• Avoiding carbonated beverages

Nausea, even in the absence of vomiting, may lead tofluid and electrolyte imbalances as the client may avoidany oral intake when nauseated. Older clients are atincreased risk for fluid and volume status imbalances.

Reduces exposure to factors that may contribute tonausea.

Women’s Health

The nursing actions for this diagnosis are the same as for Adult Health.

Mental Health

The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health.


Identify the pattern of nausea, including known precedentauras or sensations, triggering stimuli, correlation ofstimuli to perception of nausea or suggestion of nau-sea, physical signs and symptoms noted, length ofduration of symptoms, factors noted to ameliorate per-ceived nausea, and ongoing effects nausea exerts.

Develop a plan for dealing with nausea with an element ofongoing monitoring every 1 hour, or more often asneeded, for goal of lessening of perceptions or suggestednausea if the client is unable to express sensations.

• Note signs and symptoms suggestive of nausea.• Correlate signs and symptoms with other sensations,

stimuli, or events.• Identify measures to alleviate perceived sensation of

nausea, such as cold cloth on forehead, administrationof antiemetics, or other specific antinausea medications.

• Provide a therapeutic milieu to promote rest. Eliminatenoxious stimuli of noise, odors, and light. Maintainroom temperature at a comfortable and steady level.

• Determine the need for presence of the parent or signif-icant other to provide a sense of security for the infantor child. [Note client-specific management plan here.]

Collaborate with other health professionals as needed tobest address needs for the client and family.

Offer developmentally appropriate coping mechanisms toenhance the child’s sense of self-worth and likelihoodof cooperation.

A thorough assessment of the pattern assists in individu-alization of care with the intent of remaining open toongoing priorities, as well as the identification of othernursing problems.

An individualized plan of care with specific needsaddressed will best afford successful managementof nausea.

A multidisciplinary approach offers the most inclusiveand cost-effective approach for care.

Appropriate developmental approach is critical to successin creating the best effort for self-worth of the infant orchild and the parent.




••••••


Gerontic Health


Consider antiemetic agents or prokinetic agents as appro-priate.

Review the older adult’s medications to determinewhether GI problems are noted as a side effect.23

Determine whether the older adult is using herbs (aloe,senna, cascara) to alleviate problems with constipation.

Discuss with the client, if noted, stress effects on the GIsystem, and assist the client with relaxation strategiesas needed to reduce stress.

Monitor the infusion rate of tube feeding, if present, toprevent rapid feeding.

Pharmacologic therapy, when given as prescribed, canalleviate existing nausea and prevent further episodes.

Many drugs taken by older adults, such as opioids, anti-depressants, and anticholinergics, have nausea as a sideeffect.84

Using large amounts of herbal laxatives may causenausea.85

Stress can lead to reductions in peristalsis and digestiveenzymes and cause nausea, anorexia, abdominal dis-tention, or vomiting.57

Rapid feeding rates can produce nausea.86



Educate the client and caregivers on how to deal withnausea:

• Avoid sudden changes in position.• Keep the environment clean and free of noxious odors.• Keep the environment well ventilated; a fan or open

window is often helpful.• Use relaxation or diversion.• Apply cool washcloths to the face and neck.• Avoid hot baths or a hot environment.

Help the client identify foods that may precipitateepisodes of nausea.

Educate the client and caregivers in the administration ofprescribed antiemetics. Help the client to clearly iden-tify accompanying symptoms to assist the physician inprescribing the correct type of antiemetics.

Help the client to identify prescription medications, par-ticularly antibiotics and opioids, that may be causingthe nausea.

When the client believes that foods can be tolerated,encourage him or her to start with clear liquids at mod-erate temperatures and progress to soft bland foods insmall amounts.

Increases the ability to manage situations quickly andindependently. Prevents episodes of nausea from exter-nal factors.

Prevents future episodes.

Promotes a sense of independence by the client, andfacilitates obtaining appropriate prescriptions.

Facilitates changing prescriptions as necessary.

Rapidly reintroducing solid food may stimulate nauseaand vomiting.

NUTRITION, READINESSFOR ENHANCED

DEFINITION28

A state in which an individual’s pattern of nutrient intake issufficient for meeting metabolic needs and can be strength-ened.


1. Expresses willingness to enhance nutrition2. Eats regularly3. Consumes adequate food and fluid4. Expresses knowledge of healthy food and fluid choices5. Follows an appropriate standard for intake (e.g., the food

pyramid or American Diabetic Association guidelines)


6. Safe preparation and storage for food and fluids7. Attitude toward eating and drinking is congruent with

health goals

RELATED FACTORS28

1. Mechanical (pressure, shear, and friction)2. Radiation (including therapeutic radiation)3. Nutritional deficit or excess4. Thermal (temperature extremes)5. Knowledge deficit6. Irritants7. Chemical (including body excretions, secretions, and

medications)8. Impaired physical mobility9. Altered circulation

10. Fluid deficit or excess


1. New diagnoses that would necessitate nutritional alter-ations, such as Diabetes.

2. Treatments that require alterations in nutrition3. Developmental change in nutritional needs.


Risk for Imbalanced Nutrition:More Than Body Requirements.If the patient’s nutrient intake exceeds his or hermetabolic needs, then the most correct diagnosisis Risk for Imbalanced Nutrition: More than BodyRequirements. Readiness for enhanced nutritionwould be the most appropriate diagnosis if the patienthas behaviors demonstrating a tendency toward nutri-ent intake that is appropriate for metabolic needs.

EXPECTED OUTCOME

The client will verbalize plan to enhance nutrition by [date].The client will identify [number] of alterations in cur-

rent nutritional patterns that will enhance nutrition by [date].

TARGET DATES

Client education and support are key interventions forReadiness for Enhanced Nutrition. Since the client isalready demonstrating positive behaviors, it is recom-mended that target dates be no further than 3 days from thedate of initial diagnosis.

Nutrition, Readiness for Enhanced 193

••••••


Adult Health


Assist the patient in devising a dietary plan that meetsrecommended dietary allowances.

Educate the patient regarding supplements if he or she isunable to meet nutrient intake needs through dietaryintake.

Assist patient in devising schedule that facilitates regularmeals.

Have the patient verbalize appropriate food choices.

Review with the patient appropriate food handling strate-gies including refrigeration, heating, handling, etc.

Educate the patient in regard to adjusting caloric intake inaccordance with physical activity.

Educate the patient to obtain necessary information fromfood labels.

Consult with a nutritionist as necessary.Follow-up with the patient 3 days after initial diagnosis

[list date here].

Ensures that the devised plan has food choices based ondietary guidelines.

Demonstrates patient understanding of appropriate foodchoices.

Integral to safety.

Helps balance caloric intake with expenditures.

Assists the patient in making appropriate food choiceswhen considering content.

Monitors patient progress and need for modification ofplan.



NUTRITION, IMBALANCED, LESSTHAN BODY REQUIREMENTS

DEFINITION28

The state in which an individual experiences an intake ofnutrients insufficient to meet metabolic needs.


1. Pale conjunctival and mucous membranes2. Weakness of muscles required for swallowing or masti-

cation3. Sore, inflamed buccal cavity


••••••


Child Health


Assess for all contributory factors, especially reasons fordisruption in usual nutrition pattern, such as surgery,illness, or other.

Determine the ability of the caregiver to provide feedingsas determined by schedule and type, especially if for-mula is difficult to obtain or costly.

Refer to community resources for nutritional assistance,i.e., WIC. [Note referral information here.]

Teach the caregiver when and how to weigh infant oryoung child, and when to notify primary care physicianor pediatrician.

Teach the caregiver about the importance of a calm envi-ronment during feedings and about providing adequaterest periods.

Offers the fullest database for consideration of a plan thatis individualized.

Offers anticipatory guidance for prevention of inability tofollow regimen.

Provides resources for the essential plan.

Provides anticipatory support to boost the confidence ofthe caregiver.

Assists in creation of a stress-free environment to facili-tate normal digestive processes.

Women’s Health

Nursing actions for this diagnosis are the same as those for Adult Health.

Mental Health

Nursing actions for this diagnosis are the same as those for Adult Health.

Gerontic Health

Nursing actions for this diagnosis are essentially the same as those for Adult Health and Home Health.


Nursing actions for this diagnosis in the home patient are essentially the same as those for Adult Health and Home Healthwith the following additions:

A C T I O N / I N T E R V E N T I O N S R AT I O N A L E S

Monitor the patient’s ability to pay for adequate qualityand quantity of foods. Refer to community resources asappropriate.

Monitor the patient’s ability to obtain adequate qualityand quantity of foods. When travel or mobility issuesare present, refer to community resources.




Nutrition, Imbalanced, Less Than Body Requirements 195

••••••

4. Satiety immediately after ingesting food5. Reported or evidence of lack of food6. Reported inadequate food intake less than RDA (rec-

ommended daily allowance)7. Reported altered taste sensation8. Perceived inability to ingest food9. Misconception

10. Loss of weight with adequate food intake11. Aversion to eating12. Abdominal cramping13. Poor muscle tone14. Abdominal pain with or without pathology15. Lack of interest in food16. Body weight 20 percent or more below ideal17. Capillary fragility18. Diarrhea and/or steatorrhea19. Excessive loss of hair20. Hyperactive bowel sounds21. Lack of information; misinformation

RELATED FACTORS28

Inability to ingest or digest food or absorb nutrients as aresult of biologic, psychological, or economic factors.


1. Anorexia nervosa or bulimia2. Cancer3. AIDS4. Alzheimer’s disease5. Anemia6. Ostomies7. Schizophrenia, paranoid


Impaired Oral Mucous MembraneIf the oral mucous membranes are severely inflamedor damaged, food intake could be so painful that theperson ceases intake to avoid the pain. Although theend result might be Imbalanced Nutrition, Less ThanBody Requirements, initial intervention needs to beaimed at handling the oral mucosal problem.

DiarrheaIn this instance, the body cannot absorb the neces-sary nutrients because the food passes through thegastrointestinal tract too rapidly.

Ineffective Tissue PerfusionOnce the food has been ingested, digested, andabsorbed, its components must get to the cells. Ifthere is Altered Tissue Perfusion, the nutrients maynot be able to get to the cells in sufficient quantitiesto do any good.

Self-Care Deficit, Feeding, or Disturbed SensoryPerception: Visual, Olfactory, and/or Gustatory,or Ineffective Health MaintenanceOne of these diagnoses may be the primary problem.If the person does not sense hunger through the usualmeans—seeing, smelling, or tasting—or if the personthinks he or she has already eaten, then the desire toeat may not exist. Even if the person senses hunger,the inability to feed oneself, to shop for food, or toprepare food could result in less than adequate nutri-tion.

PainIf the preparation or actual eating of food increasespain level, then the patient might elect to avoid eatingto assist in pain control.

Fear, Dysfunctional Grieving, Social Isolation,Disturbed Body Image, Alteration in Self-Esteem, and Spiritual DistressThese diagnoses are psychosocial problems that canimpact nutrition. Each of these may create adecreased desire to eat, or even if food is eaten, theperson may vomit because the stomach will notaccept the food. In addition, if the person eats, he orshe may only pick at the food and not ingest enoughto maintain the body’s need for nutrients.

Deficient KnowledgeThe person may not really know how much or whatkind of food is more beneficial to his or her body.

EXPECTED OUTCOME

Will gain [number] pounds by [date].

TARGET DATES

This diagnosis reflects a long-term care problem; therefore,a target date of 5 days or more from the date of admissionwould be acceptable.


Adult Health


Include patient in collaboration efforts with dietitian/nutritionist menu to achieve desired nutritional intake.




••••••


Adult Health


• Administer appropriate medications 30 minutes beforemeals (e.g., analgesics or antiemetics); record effects ofmedications within 30 minutes of administration.

Provide a rest period of at least 30 minutes prior to meal.

Provide an environment that entices the patient to eat andfacilitates the patient’s eating:

• Reduce noxious stimuli.• Open all food containers and release odors outside the

patient’s room.• Raise the head of bed.• Open carton and packages.• Cut food into small, bite-size pieces.• Provide assistive devices (e.g., large-handled spoon or

fork, all-in-one utensil, or plate guard).

Offer small, frequent feedings every 2 to 3 hours ratherthan just three meals per day. Allow the patient toassist with food choices and feeding schedules.

Offer between-meal supplements. Focus on high-proteindiet and liquids.

Encourage significant others to bring special food fromhome.

Maintain calorie count with every meal. Review dailyintake.

As goal weight is achieved, allow patient to increasephysical activity. Coordinate with physical/occupa-tional therapy.

Monitor:• Vital signs every 4 hours while awake at [state times

here] and as required based on measurement results• Airway, sensorium, chest sounds, bowel sounds, skin

turgor, mucous membranes, bowel function, urine spe-cific gravity, and glucose level at least once per shift

• Laboratory values (e.g., electrolyte levels, hematocrit,hemoglobin, blood glucose, serum albumin, and totalprotein)

Make sure intake and output is balancing at least every72 hours.

Weigh daily at [state time] and in same-weight clothing.Have the patient empty bladder before weighing. Teachthe patient this routine for continued weighing athome.

Provide frequent positive reinforcement for:• Weight gain• Increased intake• Using consistent approach

Conserves energy for feeding self and digestion.

Three large meals a day give a sense of fullness, and thesize of servings may be overwhelming to the patient.Smaller meals facilitate gastric emptying, thus promot-ing a larger food intake overall.

Provides additional caloric intake. Providing high-proteinfoods and fluids helps prevent muscle-tissue loss.

Familiar food promotes appetite and empowers thepatient and family in regard to the diet. Allows anopportunity for teaching diet.

Monitors goal attainment or identifies areas for improve-ment.

Stimulates appetite.

Allows early detection of complications, and assists inmonitoring effectiveness of therapy.

Ensures that weight gain is not due to fluid retention.

Assesses effectiveness of therapy and interventions.Promotes the patient’s control of weight after dis-charge.



••••••


Teach the patient and significant others:• Balanced diet based on the dietary recommendations• Role of diet in health (e.g., healing, energy, and normal

body functioning)• How to keep food diary with calorie count• Adding spices to food to improve taste and aroma• Use of exchange lists• Relaxation techniques

Teach patient strategies that lend to success of goal:• Encourage the patient to eat slowly.• Avoid gas-producing foods and carbonated beverages.

• Allow rest periods of at least 30 minutes after feeding.

Educate the patient on consuming nutrient-dense foods.

Refer, as necessary, to other health-care providers.

Provides essential information needed to prevent futureepisodes.

Facilitates the digestion process.Gas-producing foods promote nausea and a feeling of

fullness.Facilitates digestion and reduces stress.

Provides ongoing support for long-term care.


There will be situations in which the patient’s nutritionalcondition has progressed or clinical situation warrants that

tube feedings or total parenteral nutrition will become nec-essary. In addition to the nursing actions for the overall nurs-ing diagnosis of Imbalanced Nutrition, Less Than BodyRequirements, the following actions should be added:


Tube Feedings


Check placement and patency prior to each feeding. Initialplacement should be checked using radiographic verifi-cation because auscultatory methods are not alwaysaccurate. Check gastric aspiration for acidic pH.87,88

Aspirate the tube prior to each feeding. If 150 mL ormore, delay feeding and notify appropriate health-careprovider.

Check the temperature of the feeding before administer-ing. The temperature should be slightly below roomtemperature.

Measure the amount of feeding exactly. Monitor infusionrate at least every 4 hours around the clock at [times].

Keep the patient in a semi-Fowler’s position or on rightside for at least 30 minutes following feeding if notcontraindicated.

If feeding is to be administered by gravity method (pre-ferred), make sure all air is out of tubing and use cau-tion to not feed too quickly.

Collaborate with the health-care team regarding initiationof protein supplements.

Monitor respiratory rate, effort, and lung sounds at leastevery 4 hours around the clock at [times].

Monitor for side effects including diarrhea.

Prevents aspiration.

Assesses for patient tolerance of enteral feeds.

Prevents abdominal cramping and reflux.

Assures consistency with prescribed feeding regimen.

Prevents reflux and aspiration of feeding.

Air in stomach creates a feeling of fullness and gas.

Allows monitoring for possible aspiration.

Diarrhea can exacerbate nutritional imbalance.(care plan continued on page 198)



••••••


Total Parenteral Nutrition


Check insertion site for warmth, redness, swelling, leak-age, and pain at least every 4 hours at [state times here].

Verify order for appropriate formula.

Check flow rate once every hour.

Implement institution appropriate standards for adminis-tration, including tubing and dressing changes, and useof filters. [Note schedule here.]

Do not administer without pump.

Check for signs and symptoms of circulatory overload atleast every 2 hours [state times here] (e.g., headache,neck vein distention, tachycardia, increased blood pres-sure, or respiratory changes).

Basic monitoring for infiltration and venous irritation.

Prevents fluid overload.

The pump allows for accurate flow rate.

Child Health

● N O T E : This diagnosis represents a long-term care issue. Therefore, a series of sub-goals of smaller amounts of weight to be gained in a lesser period of time may be neces-sary. Long-term goals are still to be formulated and revised as the patient’s statusdemands. Also, there will undoubtedly be instances in which overlap may exist for othernursing diagnoses. Specifically, as an example, in the instance of an alteration in nutri-tion related to actual failure to thrive, one must refer to appropriate role performance onthe part of the mother with consideration for holistic nursing management. It would bemost critical to include a few specific nursing process components to reflect the criticalneeds for the mother–infant dyad.

Adult health interventions can be utilized as indicated with the following considerations:


Determine all contributory factors, especially underlyingmalabsorptive conditions secondary to congenital anom-alies.

*Short bowel syndrome may constitute a long term needfor treatment with in-depth teaching needs.

Feed the infant on a regular schedule that offers nutrientsappropriate to metabolic needs. For example, an infantof less than 5 pounds will eat more often, but in lesseramounts (2 to 3 ounces every 2 to 3 hours) than aninfant of 15 pounds (4 to 5 ounces every 3 to 4 hours).

Assist or feed the patient:

• Elevate the head of bed, or place the infant in infantseat, and older infant or toddler in high chair withsafety belt in place. If necessary, hold the infant. (Thiswill be dictated in part by the patient’s status and pres-ence of various tubes and equipment.)

Variable degrees of involvement will demand appropriatefollow-up to consider the fullest needs for nursingintervention.

The stomach capacity and digestive concerns for eachpatient must be considered to realistically plan forweight gain over a slow, steady, incremental timeframe.

Appropriate attention to aesthetic, physical, and emo-tional details related to feeding helps provide the opti-mal potential for pleasant, long-lasting eating patterns.The limitation of psychological and emotional duresscannot be overemphasized, and must be considered ineach parent–child unit.

Facilitates digestion and provides interactive times forcaregiver(s) and infant or young child.



••••••


• Help the patient wash hands. For infants and toddlers,administer diaper change as needed.

• Warm foods and formula as needed, and test on wristbefore feeding the infant or child.

• Provide aids appropriate for age and physical capacityas needed, such as two-handed cups for toddlers,favorite spoon, or Velcro strap for utensils for childwith cerebral palsy.

• Offer small, age-appropriate feedings with input fromfamily members regarding the child’s preferences.

• Encourage the patient to eat slowly and to chew foodthoroughly. For infant, bubble before, during, and afterfeeding.

Role-model for parents, in a nonthreatening, nonjudg-mental manner, feeding an infant or child.

Weigh the patient on same scale and at same time [statetime here] daily. Weigh infants without clothes, olderchildren in underwear.

Teach the patient and family:• Balanced diet appropriate for age using basic food

groups• Role of diet in health (e.g., healing, energy, and normal

body functioning). If the infant is medically diagnosedas Failure to Thrive, offer appropriate emotional sup-port and allow at least 30 minutes three times a day[state times here] for exploring dyad relationships

• How to use spices and child-oriented approach inencouraging the child to eat (e.g., peach fruit salad,with peach as a face, garnished with cherries and raisinsfor eyes and nose, half of a pineapple round for mouth)

• Monitoring for possible food allergies, especially intoddlers with history of allergies

• How to weigh self appropriately, if applicable, or forparents to weigh the child

Provide positive reinforcement as often as appropriate forthe parents and child, demonstrating critical behavior.

Prevents risk of infection.

Safety for potential hyperthermic injury.

Favors self-care according to developmental capacity.

Offers the family input to best meet the child’s need andlikelihood for adequate nutrition.

Assists in tolerance of feeding.

Nonthreatening role-modeling and personal encourage-ment foster compliance and lessen anxiety.

Weight gain serves as a critical indicator of efficacy oftreatment. Maintaining consistency in weighing lessensthe number of potential intervening variables thatwould result in an inaccurate weight.

Reinforcement of desired behaviors fosters long-termcompliance, thereby empowering the family with satis-faction and confidence for ultimate self-care manage-ment with minimal intervention by others.

Women’s Health

● N O T E : Poverty and substance abuse are often associated with nutritional deficits.Remember that underweight women who are pregnant will exhibit a different pattern ofweight gain than normal-weight women. This difference exhibits a rapid weight gain atthe beginning of the first trimester of about 1 pound per week by 20 weeks. In the under-weight woman, weight gain can be as much as 18 to 20 pounds. Remember to teach theparents signs and symptoms of weight loss in the neonate.49


Collaborate with the dietitian in planning and teachingdiet:

Gives baseline from which to plan better nutrition.




••••••


Women’s Health


• Emphasize high-quality calories (cottage cheese, leanmeats, fish, tofu, whole grains, fruits, and vegetables).

• Avoid excess intake of fats and sugar.• Assist the patient in identifying methods to keep

caloric intake within the recommended limit.

Verify pre-pregnant weight.

Determine whether weight loss during first trimester isdue to nausea and vomiting.

Check activity level against daily dietary intake.

Check for food intolerances.

Check environmental influences:• Hot weather• Cultural practices• Pica eating• Economic situation• Ascertain economic status and ability to buy food• Monitor woman’s emotional response to the pregnancy

and to additional weight gain

Assist in planning realistic diet changes within thepatient’s means and according to the patient’s particu-lar needs and habits.

● N O T E : Dieting is never recommended during pregnancy because it deprives themother and fetus of nutrients needed for tissue growth, and because weight loss isaccompanied by maternal ketosis, a direct threat to fetal well-being.5,62

Identify additional caloric needs and sources of thosecalories for the nursing mother.89,90

• An additional 500 calories/day above normal dietaryintake is needed to produce adequate milk (dependingon the individual, a total of 2500 to 3000 calories/day).

• Additional fluids are necessary to produce adequatemilk.

Collaborate with nutritionist to provide a health dietarypattern for the lactating mother.

Monitor the mother’s energy levels and health mainte-nance:

• Does she complain of fatigue?• Does she have sufficient energy to complete her daily

activities?• Does the dietary assessment show irregular dietary

intake?• Is she more than 10 percent below the ideal weight for

her body stature?For breastfeeding the newborn or neonate during the first

6 months, teach the mother:• The major source of nourishment is human milk.• Vitamin supplements can be used as recommended by

physician:• Vitamin D• Fluoride• If indicated, iron

Provides basis for ensuring good nutrition, and assists insuccessful breastfeeding.



••••••


The infant should be taking in approximately 420 mLdaily soon after birth and building to 1200 mL daily atthe end of 3 months.

Monitor for fluid deficit at least daily:• “Fussy baby,” especially if immediately after feeding• Constipation (remember breastfed babies have fewer

stools than formula-fed babies)Weight loss or slow weight gain: Closely monitor the

baby, the mother, and nursing routine:• Is the baby getting empty calories (e.g., a lot of water

between feedings)?• Avoid nipple confusion, which results from switching the

baby from breast to bottle and vice versa many times.• Instruct the mother in “cup feeding” of nursing infant

to ensure adequate fluid intake and avoid nipple confu-sion.50,54,59

• Count the number of diapers per day (should have sixto eight very wet diapers per day).

• Is there intolerance to mother’s milk or bottle formula?• Is there illness or lactose intolerance?• Infrequent nursing can cause slow weight gain.

Provides for good nutritional status of the newborn.

Allows early intervention for this problem.

Provides the infant with nutrition, while supporting thebreastfeeding mother.63

Mental Health

● N O T E : Because of long-term care requirements for these clients, target dates shouldbe determined in weeks or months, not hours or days.


Do not attempt teaching or long-term goal setting withthe client until concentration has improved (symptomof starvation).

Establish contract with the client to remain on prescribeddiet and not to perform maladaptive behavior (e.g.,vomiting or use of laxatives). State specific behaviorand rewards for the client here.

• Plan gradual refeeding with incremental progressionProvide vitamin and mineral supplements as prescribed.Place the client on 24-hour constant observation (this will

be discontinued when the client ends maladaptivebehavior, or at specific times that nursing staff assessare low risk).

Place the client on constant observation during meals andat high-risk times for maladaptive behavior (such as1 hour after meals or while using the bathroom). Thisaction will take effect when the preceding one is dis-continued.

Do not allow the client to discuss weight or calories.Excessive discussion of food is also discouraged.

Require the client to eat prescribed diet (all food on trayeach meal except for those three or four foods theclient was allowed to omit in the admission contract).List the client’s omitted food here.

Starvation can affect cognitive functioning.91

Provides the client with a sense of control, and clearlyestablishes the consequences and rewards for behavior.Weight gain of 2 to 3 pounds/week for inpatient careand 0.5 to 1 pound/week is reasonable.92

Provides consistency and structure during the stressfulearly period of treatment.

Provides support for the client during stressful period.

Decreases the client’s abnormal focus on food and pro-motes normal eating patterns. This behavior is moreindicative of starvation than an eating disorder.91

Promotes the client’s sense of control and participation indecision-making within appropriate limits.




••••••


Mental Health


Sit with the client during meals, and provide positive sup-port and encouragement for the feelings and concernsthe client may have.

Do not threaten the client with punishment (tube feedingor IVs).

Report all maladaptive behavior to the client’s primarynurse or physician for confrontation in individual ther-apy sessions.

Spend [number] minutes with the client every [number]minutes to establish relationship.

Respond to queries related to fears of being required togain too much weight with reassurance that the goal oftreatment is to return the client to health, and that he orshe will not be allowed to become overweight. Alsoreinforce the risks of eating disorder.

Provide the client with information on bingeing and purg-ing and the impact they have on dieting and the body.

If the client vomits, have him or her assist with thecleanup, and require him or her to drink an equalamount of a nutritional replacement drink.

Schedule the client for group therapy (specific encourag-ing behavior should be listed here, such as assisting theclient to complete morning care on time or other inter-ventions that are useful for this client).

Encourage the client’s family by [list specific encourag-ing behaviors for this family] to attend family therapysessions.

Assist the client with clothing selection. Clothes shouldnot be too loose, hiding weight loss, or too tight, assist-ing the client to feel overweight even though appropri-ate weight is achieved.

Have the client develop a daily food diary that recordstime of day, amount and type of food, and binge orpurge behavior with feelings and thoughts.

When maintenance weight is achieved, assist the clientwith selection of appropriate foods from hospitalmenu.

When maintenance weight is achieved, refer to thedietitian for teaching about balanced diet and homemaintenance.

When maintenance weight is achieved, refer to occupa-tional therapist for practice with menu planning,trips to grocery stores to purchase food, and mealpreparation.

When maintenance weight is achieved, plan passes withthe client for trips to restaurants for meals.

Provides a positive, supportive context for the client.91

Provides the client with increased information about hisor her behaviors. Does not impact calorie loss anddestroys the tissue of the upper GI tract.93

Provides natural consequences for behavior.

Provides support from peers and a source of honest feed-back.91

Provides support for the family and an opportunity for thefamily to work through their concerns together.91

Altered body image makes it difficult for clients to makeappropriate choices; honest feedback and support fromthe nursing staff makes the transition to “healthy”choices easier.

Assists clients in linking thoughts with behaviors.93

As symptoms of starvation are resolved, the client is bet-ter able to make appropriate choices, and gradualreturning of control prepares the client to acceptresponsibility at discharge.91

Provides further information to the client to assist inmaintaining desired weight. Provides visible rewardfor weight maintenance.



••••••


Allow the client to exercise [number] minutes [number]times per day while supervised (this will be altered asthe client reaches maintenance weight).

Allow the client to do the following exercises during theexercise period. (These are graded to the client’s physi-cal condition. Consultation with the occupational thera-pist is useful.)

Allow the client [number] of [number] minute walks onhospital grounds with a staff member each day.

Meet with family/significant others [number] minutes[number] times per week to discuss positive familyinteractions and support for client. In this meetingmodel appropriate communication and develop plan forresponding to the client’s eating patterns. Refer tonursing actions for Family Processes, Interrupted formore in depth plan to address family interaction issues.

• Facilitate the development of a specific plan for ongo-ing care and support after discharge. [Note that planhere with the names of contact persons.]

Assists the client in developing realistic goals for exerciseaccording to age and ability.

Family support, education, and therapy improve out-comes of eating disorder treatment.92

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized with the aging client.

● N O T E : National Clinical Guidelines recommend in cases of clients with weight lossproblems, that the client or their proxy have a full discussion of their health-care wisheswith a health-care professional. A discussion of the treatment goals and the resident’songoing quality of life, should be initiated. The decision they make should be docu-mented. Certain causes of malnutrition may be irreversible.94


Monitor and record client’s weight each week.

Monitor and record client’s hydration status regularly.Elders should ingest between 1500 and 2000 mLper day.94

Ensure environmental conditions at mealtime are con-ducive to adequate intake:

• Palatable, minimally restrictive diet• Pleasant, well lit, unhurried mealtimes• Social environment at mealtime94

For clients with dependency in eating, establish andadhere to restorative feeding program.94

Involve family with visits or assistance with feeding atmealtimes.94

Use calorie-dense foods whenever possible.94

Initiate or maintain an exercise program when appro-priate.94

Offer nutritional supplements between meals and not tosubstitute for calorie intake at meals.94

Evaluate the client for possible depression and treataccordingly.94



Recognition of feeding problems and proper feeding tech-niques may improve weight loss in nursing homes.94

Exercise may increase dietary intake.94

To increase dietary intake.94

Depression may be a reversible cause of decreaseddietary intake.94



NUTRITION, IMBALANCED, MORETHAN BODY REQUIREMENTS, RISKFOR AND ACTUAL

DEFINITIONS28

Risk for Imbalanced Nutrition: More Than BodyRequirements The state in which an individual is at riskof experiencing an intake of nutrients that exceeds metabolicneeds.

Imbalanced Nutrition: More Than Body Require-ments The state in which an individual is experiencing anintake of nutrients that exceeds metabolic needs.


A. Risk for (presence of risk factors such as):1. Reported use of solid food as major food source

before 5 months of age2. Concentrating food intake at end of day


••••••


Gerontic Health


Consult with a pharmacist to determine drugs that mightbe producing anorexia.94

Drugs have been found to be a cause of weight loss inlong term care residents.94


The long-term nature of this diagnosis requires long-term goals that are measured in weeks or months. Short-term goalscan be established to assess patient understanding of interventions.


Monitor the client’s ability to pay for adequate quantityand quality of food. Refer client to communityresources for assistance as appropriate.

Reduce associated factors, for example:• Minimize noxious odors by using foods that require

minimal cooking; or if someone else is cooking for theclient, arrange for the client to be away from the cook-ing area.

• Provide social atmosphere desired by the client.• Plan medications to decrease pain and nausea around

mealtime.• Plan meals away from area where treatments are per-

formed.• Maintain oral hygiene before and after meals. Instruct

the client and family in proper brushing, flossing, anduse of water pick.

• Facilitate client’s request for or preparation of favoritefoods.

• Avoid foods that contribute to noxious symptoms suchas gas, nausea, or GI distress.

• Discourage fasting. Teach stress-reduction exercises.• Maintain exercise program as tolerated.

Teach to add high-calorie, high-protein, and high-fatitems to meal preparation activities (e.g., use milk insoups; add cheese to food, and use butter or margarinein soups and vegetables).

Teach or provide assistance to rest before meals. If theclient is doing the meal preparation, teach to cooklarge quantities and freeze several meals at a time andto seek assistance in meal preparation when fatigued.

Financial factors and availability of food should beaddressed prior to other factors.

Provides positive environment to promote nutritionalintake.

Promotes weight gain and prevents loss of muscle mass.

Provides optimal conditions to avoid excess fatigue.


Nutrition, Imbalanced, More Than Body Requirements, Risk For and Actual 205

••••••

3. Reported or observed obesity in one or both parents4. Reported or observed higher baseline weight at

beginning of each pregnancy5. Rapid transition across growth percentiles in infants

or children6. Pairing food with other activities7. Observed use of food as reward or comfort measure8. Eating in response to internal cues other than

hunger, such as anxiety9. Eating in response to external cues such as time of

day or social situation10. Dysfunctional eating patterns

B. More Than Body Requirements1. Triceps skin fold greater than 15 mm in men, or 25

mm in women2. Weight 20 percent more than ideal for height and

frame3. Eating in response to external cues such as time of

day or social situation4. Eating in response to internal cues other than hunger

(e.g., anxiety)5. Reported or observed dysfunctional eating pattern

(e.g., pairing food with other activities)6. Sedentary activity level7. Concentrating food intake at end of day

RELATED FACTORS28

1. Risk for: The risk factors also serve as the related fac-tors.

2. More Than Body Requirements: Excessive intake inrelation to metabolic needs.


1. Alzheimer’s disease2. Morbid obesity3. Hypothyroidism4. Disorders requiring medicating with corticosteroids

5. Any disorder resulting in prolonged immobility6. Metabolic syndrome


Deficient KnowledgeThe patient, because of his or her cultural back-ground, may not know the appropriate food groupsand the nutritional value of the foods. In addition, thecultural beliefs held by a patient may not value thin-ness. Therefore, the people of a particular culture mayactually promote obesity.

Ineffective Health MaintenanceBecause of other problems, the patient may not beable or willing to modify nutritional intake even thoughhe or she has information about good nutritional pat-terns.

Other Possible DiagnosesSeveral diagnoses from the psychosocial realm maybe the underlying problem that has resulted in Risk foror More Than Body Requirements. Powerlessness,Self-Esteem Disturbance, Social Isolation, DisturbedBody Image, or Ineffective Individual Coping may alsoneed to be dealt with in the patient who is at risk foror actually has Imbalanced Nutrition, More Than BodyRequirements.

EXPECTED OUTCOME

Will lose [number] pounds by [date].Will verbalize plan for healthy weight loss by [date].Will identify [number] behaviors that facilitate weight

loss by [date].

TARGET DATES

Because this diagnosis reflects long-term care in terms ofboth cause and correction, a target date of 5 days or morewould not be unreasonable.


Adult Health


Assist the patient to identify dysfunctional eating habits,during first day of hospitalization, by:

• Associating times of eating and types of food with cor-responding events (e.g., in response to internal cues orin response to external cues)

• Review the patient’s dietary and activity patterns

Discuss with the patient potential or real motivation fordesiring to lose weight at this time.

Provides basic information needed to plan changes indysfunctional habits to begin weight-loss program.

Assists in understanding the patient’s rewards for goals,and assists in establishment of goals and rewards.




••••••


Adult Health


Discuss with the patient past attempts at weight loss andfactors that contributed to their success or failure.

Weigh the patient daily at [state time]. Teach the patientto weigh self at the same time each morning in sameclothing. Help the patient to establish a graphic toallow visualization of progress (e.g., bar chart, chartwith gold star for each weight-loss day).

Limit the patient’s intake to number of calories recom-mended by the physician and/or nutritionist.

Have the patient design own weight-loss plan at least 3days prior to discharge to allow practice and revisionas necessary:

• Maintain accurate calorie count every shift. Reviewevery 24 hours.

Collaborate with physical therapist in establishing anexercise program.

Assist the patient in selecting an exercise program byproviding the patient with a broad range of options,and have the client select one he or she will enjoy.[Note client’s plan for exercise here.]

Assist the patient to establish a food diary, during firstday of hospitalization, which should be maintaineduntil weight has stabilized to desired goal. The diaryshould include specific details of eating habits includ-ing the foods, where consumed, when consumed, andspecific factors surrounding consumption and physicalactivity.

Teach the patient the principles of a balanced diet, orrefer to dietitian for instructions, at least 3 days beforedischarge.

Review pros and cons of alternate weight-loss optionswith the patient:

• Fad diets• Enrollment in weight loss programs• Surgery

Demonstrate adaptations in eating that could promoteweight loss:

• Smaller plate• One-half of usual serving• No second servings

Suggest that the patient contract with a significant otheror home health nurse prior to discharge. Consult withthe family and visitors regarding importance of thepatient’s adhering to diet. Caution against bringingfood, etc., from home.

Provides increased individualization and continuity ofcare, which facilitates the development of a therapeuticrelationship.95

Provides a visible means of ascertaining weight-lossprogress.

Reduces calories to promote weight loss yet maintainbody’s nutritional status.

Allows the patient to assume control for long-term ther-apy. The more the patient is involved in planning care,the higher the probability for compliance.

Monitors progress toward goals. Gives tangible feedbackto patient.

Exercise burns calories and tones muscles. Assists in nar-rowing the range between calories consumed and calo-ries burned. Facilitates development of adaptive copingbehaviors.

Helps the patient to identify real intake and to identifybehavioral and emotional antecedents to dysfunctionaleating behavior.32,33,96

Provides basic knowledge needed to control weight athome. Promotes self-care. Promotes the patient’s per-ception of control.

Promotes safety in weight-loss plan. Avoids serious com-plications such as heart failure due to questionableweight-loss ideas.

Assists in behavior modification needed to lose weight.

Provides added reinforcement and support for continuedweight loss. Involves others in supporting the patient inweight-loss effort.


Nutrition, Imbalanced, More Than Body Requirements, Risk For and Actual 207

••••••


Refer to community resources at least 3 days before dis-charge from hospital. Refer the patient and family topsychiatric nurse practitioner for appropriate tech-niques to use at home, as well as assistance with guilt,anxiety, etc. over being obese.

Provides long-range support for continued success withweight loss.

Child Health

Orders are the same as for the adult. Make actions specific to the child according to the child’s developmental level.

Women’s Health


Verify the pre-pregnancy weight.Obtain a 24-hour diet history. Ask the patient to select a

typical day.Calculate the woman’s calorie and protein intake.Rule out excessive edema and hypertension. Measure

ankles and abdominal girth and record. Remeasureeach day. Measure blood pressure every 4 hours whilethe patient is awake at [state times here].

Encourage the client to increase her activity by: Joiningexercise groups for pregnancy (usually found in child-birth classes in community):

• Joining swim exercise groups for pregnancy (usuallyfound at YWCAs or community centers)

Refer to appropriate support groups for assistance inexercise programs for the pregnant woman (e.g., physi-cal therapist, local groups that have swimming classesfor pregnant women, and childbirth classes).

If recommended intake is 2400 calories/day but 24-hourdiet recall reveals a higher caloric intake:

• Recommend reduction of fat in diet (e.g., decreaseamount of cooking oil used, use less salad dressing andmargarine, cut excess fat off meat, and take skin offchicken before preparing).

• Monitor size of food portions.• Stress appetite control with high-quality sources of

energy and protein.Assist mothers with cultural or economic restrictions to

introduce more variety into their diets.Stress that weight gain is the only way the fetus can be

supplied with nourishment.Point out that added body fat will be burned and will pro-

vide necessary energy during lactation (breastfeeding).Assist pregnant adolescents within 3 years of menarche to

plan diets that have needed additional nutrients.Discourage any attempts at weight reduction or dieting.

Provides basis for planning diet with the patient.

Assists in maintaining desired weight gain; improvesmuscle tone and circulation.

Basic measures and teaching factors to assist in weightcontrol.

Diet has to be planned to meet the growth needs of theadolescent as well as those of the fetus.

Dieting is never recommended during pregnancy because itdeprives the mother and the fetus of nutrients needed fortissue growth, and because weight loss is accompaniedby maternal ketosis, a direct threat to fetal well-being.70




••••••


Women’s Health


A satisfactory pattern of weight gain for the averagewoman is:

• 0 weeks of gestation 650 g (approximately 1.5 lb)• 20 weeks of gestation 4000 g (approximately 9.0 lb)• 30 weeks of gestation 8500 g (approximately 19.0 lb)• 40 weeks of gestation 12,500 g (approximately 27.5 lb)5

Over the course of the pregnancy, a total weight gain of25 to 35 pounds is recommended for both nonobeseand obese pregnant women. During the second andthird trimesters, a gain of about 1 pound/week is con-sidered desirable.5

Mental Health

Nursing actions for the Mental Health client with this diagnosis are the same as those actions in Adult Health with the fol-lowing considerations:


Monitor client’s taking psychotropic (especially atypicalantipsychotics) medications for increased weight, bloodpressure, fasting plasma glucose, and lipid profile.

If the client shows weight gain of 5 percent or more frombaseline, consult with physician to prescribe a moreweight/metabolic neutral medication.

Teach the patient about this side effect of the medica-tions, and the need to monitor his or her weight, bloodsugars, and lipids.

Spend [number] minutes per day discussing client’s per-ception of his or her weight and nutrition needs.

Spend [number] minutes per day planning weight man-agement program with client that is based on theclient’s perceptions of need and goals. Plan needs toinclude diet alterations and exercise. [Note plan herewith nursing actions needed to support the plan.]

• Develop, with the client, specific behavioral rewardsfor meeting diet and exercise goals. Note these rewardsand goals with weight management plan.

Consult with the nutritionist to develop a diet plan and toprovide nutritional education. [Note schedule for meet-ings with nutritionist here, and client’s plan with theassistance needed from nursing to implement the plan.]

Consult with physical, recreational, and occupationaltherapy to assist client in developing an exercise andrecreational activity plan.

Refer client to community support systems for diet andexercise. Note those resources here. Provide client withphone numbers and names of contact persons.

Meet with client’s support system to review currentdietary needs and to develop a plan that can be imple-mented in the home.

Atypical antipsychotics are associated with greater meta-bolic dysfunction, including weight gain, changes inserum triglycerides, and glycemic control.96

Modest weight loss can have a significant impact on riskfactors. Metabolically neutral medications have beendemonstrated to improve weight and other metabolicmeasures.96

Increases the client’s sense of control.

Change depends on the client’s perception of the prob-lem.97

Successful weight management plans have been behav-ioral and included diet and exercise.96

Positive reinforcement increases behavior.

Developing a plan that includes activities the clientenjoys increases potential for continuing the activity.


Swallowing, Impaired 209

••••••



Assist the client in identifying lifestyle changes that maybe required:

• Regular exercise at least three times per week, whichincludes stretching and flexibility exercises and aerobicactivity (20 minutes) at target training rate.

• Nutritional habits should include decreasing fat andsimple carbohydrates, and increasing complex carbohy-drates.

Assist the client and family in identifying cues other thanfocus on weight and calories, such as feeling of well-being, percentage of body fat, increased exerciseendurance, and better-fitting clothes.

Have the client and family design personalized plan:• Menu planning• Decreased fats and simple carbohydrates, and increased

complex carbohydrates• Regular, balanced exercise• Lifestyle changes

Assist clients in identifying local resources for obtainingand ideal weight (e.g., support groups, WeightWatchers).

Assist client in modifying their environment to facilitatehealthy food choices (pantry and refrigerator).

Monitor the client’s ability to pay for healthy foods.Some clients may select calorie dense foods that areless expensive. Refer client to community resources forfinancial assistance with food as appropriate.

Knowledge and support provide motivation for changeand increase the potential for positive outcomes.

Excess focus on the weight, as measured by the scale,and on calorie counting may increase the probability offailure and encourage the pattern of repeated weightloss followed by weight gain. This pattern results inincreased percentage of body fat.

A personalized plan improves the probability of adher-ence to the plan.

Support facilitates success in obtaining and maintainingideal weight.

Improves probability of adherence to selected plan.

Improves probability of adherence to selected plan.

Gerontic Health

Nursing actions for the gerontic patient with this diagnosis are the same as those actions in Adult Health and Home Health.

SWALLOWING, IMPAIRED

DEFINITION28

Abnormal functioning of the swallowing mechanism associ-ated with deficits in oral, pharyngeal, or esophageal struc-ture or function.


1. Pharyngeal phase impairmenta. Altered head positionb. Inadequate laryngeal elevationc. Food refusald. Unexplained feverse. Delayed swallowingf. Recurrent pulmonary infections

g. Gurley voice qualityh. Nasal refluxi. Choking, coughing, or gaggingj. Multiple swallowingk. Abnormality in pharyngeal phase by swallowing study

2. Esophageal phase impairmenta. Heartburn or epigastric painb. Acidic-smelling breathc. Unexplained irritability surrounding mealtimed. Vomitus on pillowe. Repetitive swallowing or ruminatingf. Regurgitation of gastric contents or wet burpsg. Bruxismh. Nighttime coughing or awakeningi. Observed evidence of difficulty in swallowing (e.g.,

stasis of food in oral cavity, coughing, or choking)


j. Hyperextension of head, arching during or aftermeals

k. Abnormality in esophageal phase by swallow studyl. Odynophagiam. Food refusal or volume limitingn. Complaints of something stucko. Hematemesisp. Vomiting

3. Oral phase impairmenta. Lack of tongue action to form bolusb. Weak suck resulting in inefficient nipplingc. Incomplete lip closured. Food pushed out of mouthe. Slow bolus formationf. Food falls from mouthg. Premature entry of bolush. Nasal refluxi. Long meals with little consumptionj. Coughing, choking, or gagging before a swallowk. Abnormality in oral phase of swallow studyl. Piecemeal deglutitionm. Lack of chewingn. Pooling in lateral sulcio. Sialorrhea or droolingp. Inability to clear oral cavity

RELATED FACTORS28

1. Congenital deficitsa. Upper airway anomaliesb. Failure to thrive or protein energy malnutritionc. Conditions with significant hypotoniad. Respiratory diseasese. History of tube feedingf. Behavioral feeding problemsg. Self-injurious behaviorh. Neuromuscular impairment (e.g., decreased or absent

gag reflex, decreased strength or excursion of mus-cles involved in mastication, perceptual impairment,facial paralysis)

i. Mechanical obstruction (e.g., edema, tracheostomytube, tumor)

j. Congenital heart diseasek. Cranial nerve involvement

2. Neurologic problemsa. Upper airway anomaliesb. Laryngeal abnormalitiesc. Achalasiad. Gastroesophageal reflux diseasee. Acquired anatomic defectsf. Cerebral palsyg. Internal traumah. Tracheal, laryngeal, esophageal defectsi. Traumatic head injury

j. Developmental delayk. External traumal. Nasal or nasopharyngeal cavity defectsm. Oral cavity or oropharyngeal abnormalitiesn. Premature infants


1. Cerebrovascular accident2. Any neuromuscular diagnosis (e.g., myasthenia gravis,

muscular dystrophy, cerebral palsy, Parkinson’s disease,Alzheimer’s disease, poliomyelitis)

3. Hyperthyroidism4. Any medical diagnosis related to decreased level of con-

sciousness (e.g., seizures, concussions, increasedintracranial pressure)

5. Tracheoesophageal problems (e.g., fistula, tumor, edema,or presence of tracheostomy tube)

6. Anxiety


Impaired Oral Mucous MembraneImpaired Swallowing implies that there is a mechani-cal or physiologic obstruction between the orophar-ynx and the esophagus. An Impaired Oral MucousMembrane indicates that only the oral cavity isinvolved. Structures below the oral cavity, per se, arenot affected. If liquids or solids are able to passthrough the oral cavity, even though pain or difficultymight be present, there will be nothing obstructing itspassage through the esophagus to the stomach.Therefore, if solids or liquids are able to pass into thestomach without crowing, coughing, or choking, theappropriate nursing diagnosis is not ImpairedSwallowing.

Imbalanced Nutrition, Less Than BodyRequirementsCertainly Imbalanced Nutrition, Less Than BodyRequirements would be a consideration and probablya secondary problem to Impaired Swallowing.Choosing between the two diagnoses would be basedon the related factors, with Impaired Swallowing tak-ing priority over the Impaired Nutrition initially.

EXPECTED OUTCOME

Will be able to freely swallow [solids/liquids] by [date].

TARGET DATES

Because Impaired Swallowing can be life-threatening, thepatient should be checked for progress daily. After the con-dition has improved, progress could be checked at 3-dayintervals.


••••••


Swallowing, Impaired 211

••••••


Adult Health


Monitor for lesions or infectious processes of the mouthand oropharynx at least once per shift.

Test, before every offering of food, fluid, etc., for pres-ence of gag reflex.

Before offering food or fluids, test swallowing capacitywith clear, sterile water only. Have suctioning equip-ment and tracheostomy tray on standby in the patient’sroom.

Maintain appropriate upright position during feeding.Stay with the patient while he or she tries to eat.

Be supportive to the patient during swallowing efforts.Teach the patient who has had supraglottic surgery an

alternate method of swallowing:• Have the patient then perform a Valsalva maneuver as

he or she is swallowing.• Teach at least one other family member or significant

other how to support the patient in alternate swallow-ing, suctioning, Heimlich maneuver, etc.

Refer as needed to speech/swallow therapy and otherhealth-care team members.

Lesions or ulcers in the mouth promote difficulty in swal-lowing.

To prevent choking and aspiration.

Provides equipment needed in case of aspiration or respi-ratory obstruction emergency.

Gravity assists in facilitation of swallowing.Basic safety measure for the patient who has difficulty in

swallowing.Swallowing difficulty is very frustrating for the patient.Facilitates active swallowing and support for the patient

as he or she begins to adapt to impaired swallowing.

Collaboration supports a holistic approach to patient care.

Child Health


Monitor for contributory factors, especially palate forma-tion, possible tracheoesophageal fistula, or other con-genital anomalies.

Maintain the infant in upright position after feedings forat least 11/2 hours.

Address anticipatory safety needs for possible choking:• Have appropriate suctioning equipment available.• Teach the parents CPR.• Provide parenting support for CPR and suctioning.

• Assist the family to identify ways to cope with swal-lowing disorder (e.g., the need for extra help in feed-ing). Refer to health-care specialists to facilitate this,especially occupational therapist.

Administer medications as ordered. Avoid powder or pillforms. Use elixirs or mix as needed.

A thorough assessment will best identify those patientswho have greater-than-usual likelihood of swallowingdifficulties due to structural, acquired, or circumstantialconditions.

An upright position favors, by gravity, the digestion andabsorption of nutrients, thereby decreasing the likeli-hood of reflux and resultant potential for choking.

Usual anticipatory airway management is appropriate inlong-term patient management. Education and teachingconcerns can be addressed in a supportive environ-ment, thereby reducing anxiety in event of cardiopul-monary arrest secondary to impaired swallowing.

Appropriate individualization fosters input and respect forhow to best meet needs of client in a way the familycan relate.

Pills or powders may increase the likelihood of impairedswallowing in young children and infants. Appropriatemixing with fruit syrups or using manufacturer’s elixiror suspension form of the drug lessens the likelihoodof impaired swallowing.




••••••


Child Health


If training is in conjunction with tracheostomy removal,involve all the health team members to appropriatelycoordinate plan. [Note client’s plan here with assis-tance needed by nursing to facilitate plan.]

Provides the most realistic and holistic plan of care.

Women’s Health

The nursing actions for a woman with the nursing diagnosis of Impaired Swallowing are the same as those for AdultHealth.

Mental Health

● N O T E : The following nursing actions are specific considerations for the mentalhealth client who has Impaired Swallowing that is caused or increased by anxiety. Referto Mental Health nursing actions for the diagnosis of Anxiety for interventions related todecreasing and resolving the client’s anxiety. If swallowing problems are related to aneating disorder, refer to Mental Health nursing actions for Imbalanced Nutrition, LessThan Body Requirements, for additional nursing actions.


Provide a quiet, relaxed environment during meals by dis-cussing with the client the situations that increase anxi-ety and excluding those factors from the situation.Provide things such as favorite music and friends orfamily that increase relaxation. [Note information pro-vided by the client here, especially those things thatneed to be provided by the nursing staff.]

Provide medications in liquid or injectable form. [Noteany special preference the client may have in presenta-tion of medications here.]

Teach the client deep muscle relaxation. (Refer to theMental Health nursing actions for Anxiety for actionsrelated to decreasing anxiety.)

Discuss with the client foods that are the easiest and themost difficult to swallow. [Note information from thisdiscussion here. Also note time and person responsiblefor this discussion.]

Plan the client’s most nutritious meals for the time of dayhe or she is most relaxed, and note that time here.

Provide the client with high-energy snacks several timesduring the day. [Note snacks preferred by the clientand time they are to be offered here.]

Assign primary nurse to sit with the client 30 minutes(this can be increased to an hour as the client toleratesinteraction time better) 2 times a day to discuss con-cerns related to swallowing. (This can be included inthe time described under the nursing actions forAnxiety.) As the nurse–client relationship moves to a

Promotes the client’s control and facilitates relaxationresponse, thus inhibiting the sympathetic nervoussystem response.27,95

Liquids are easier to swallow than tablets. Providingmedications by injection would prevent any swallow-ing problems.

Promotes client control and inhibits the sympatheticnervous system response.

Promotes client control.

Provides additional calories in frequent small amounts.

Provides increased individualization and continuity ofcare, facilitating the development of a therapeutic rela-tionship. The nursing process requires that a trustingand functional relationship exist between nurse andclient.95 Change depends on the client’s perception ofthe problem.97


Thermoregulation, Ineffective 213

••••••


working phase, discussion can include factors that pre-cipitated the client’s focus on swallowing. These fac-tors could be a trauma directly related to swallowing,such as an attack in which the client was choked or inwhich oral sex was forced.

Teach the client and client’s support system nutrition fac-tors that will improve swallowing and maintain adequatenutrition. [Note here the names of persons the clientwould like included in this teaching. Also note timearranged and person responsible for this teaching here.]

Promotes long-term support for assistance with problem.

Gerontic Health

Nursing actions for the gerontic patient with this diagnosis are the same as those for Adult Health and Psychiatric Health.



Teach measures to decrease or eliminate ImpairedSwallowing:

• Principles of oral hygiene• Small pieces of food or pureed food as necessary• Aspiration precautions (e.g., eat and drink sitting up,

do not force-feed or fill mouth too full, and CPR)• Proper nutrition and hydration• Use of adaptive equipment as required

Teach to monitor for factors contributing to ImpairedSwallowing (e.g., fatigue, obstruction, neuromuscularimpairment, or irritated oropharyngeal cavity, on atleast a daily basis).

Involve the client and family in planning, implementing,and promoting reduction or elimination of ImpairedSwallowing by establishing regular family conferencesto provide for mutual goal setting and to improve com-munication.

Assist the client and family in lifestyle changes that maybe required:

• The client may need to be fed.• Mealtimes should be quiet, uninterrupted, and at con-

sistent times on a daily basis.• The client may require special diet and special utensils.

Prevents or diminishes problems. Promotes self-care andprovides database for early intervention.

Goal setting and communication promote positiveoutcomes.

Knowledge and support provide motivation for changeand increase the potential for a positive outcome.

THERMOREGULATION, INEFFECTIVE

DEFINITION28

The state in which the individual’s temperature fluctuatesbetween hypothermia and hyperthermia.


1. Fluctuations in body temperature above or below thenormal range

2. Cool skin3. Cyanotic nail beds4. Flushed skin5. Hypertension6. Increased respiratory rate7. Pallor (moderate)8. Piloerection9. Reduction in body temperature below normal range

10. Seizures or convulsions11. Shivering (mild)


12. Slow capillary refill13. Tachycardia14. Warm to touch

RELATED FACTORS28

1. Aging2. Fluctuating environmental temperature3. Trauma or illness4. Immaturity


1. Any infection2. Any surgery3. Septicemia


HyperthermiaHyperthermia means that a person maintains a bodytemperature greater than what is normal for himself orherself. In Ineffective Thermoregulation, the client’stemperature is changing between Hyperthermia andHypothermia. If the temperature measurement isremaining above normal, the correct diagnosis isHyperthermia, not Ineffective Thermoregulation.


••••••

HypothermiaHypothermia means that a person maintains a bodytemperature below what is normal for himself or her-self. If the temperature is consistently remainingbelow normal, the correct diagnosis is Hypothermia,not Ineffective Thermoregulation.

Risk for Imbalanced Body TemperatureWith this diagnosis, the patient has a potential inabil-ity to regulate heat production and heat dissipationwithin a normal range. The key point to remember isthat a temperature abnormality does not exist yet, butthe risk factors present indicate such a problem coulddevelop. If the temperature measurements are fluctu-ating between hypothermia and hyperthermia, thecorrect diagnosis is Ineffective Thermoregulation.

EXPECTED OUTCOME

Will maintain a body temperature between 97 and 99�F by[date].

TARGET DATES

Initial target dates will be stated in terms of hours. After sta-bilization, an appropriate target date would be 3 days.


Adult Health


Monitor vital signs at least every hour on the hour. [Notetimes here.]

Maintain room temperature at all times at 72�F. Providewarmth or cooling as needed to maintain temperaturein desired range; avoid drafts and chilling for thepatient.

Reduce stress for the patient. Provide quiet, nonstimulat-ing environment.

If the patient is hypothermic, see nursing actions forHypothermia.

If the patient is hyperthermic, see nursing actions forHyperthermia.

Make referrals for appropriate follow-up before dismissalfrom hospital.

Monitors basic trends in temperature fluctuations. Permitsearly recognition of ineffective thermoregulation.

Offsets environmental impact on thermoregulation.

Assists body to maintain homeostasis. Stress could con-tribute to problems with thermoregulation as a result ofincreased basal metabolic rate.

Thermoregulation problems may vary from hypothermiato hyperthermia.

Provides long-range, cost-effective support.

Child Health


Protect the child from excessive chilling during bathingor procedures.

Evaporation and significant change of temperature foreven short periods of time contribute to heat loss forthe young child or infant, especially during illness.


Thermoregulation, Ineffective 215

••••••

Women’s Health

This nursing diagnosis will pertain to women the same as it would for any other adult. The reader is referred to the AdultHealth and Home Health nursing actions for this diagnosis.

Mental Health

The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health.

Gerontic Health

● N O T E : Normal changes of aging can contribute to altered thermoregulation. Age-related changes that may be associated with altered thermoregulation are a decrease infebrile response, inefficient vasoconstriction, decreased cardiac output, decreased subcu-taneous tissue, diminished shivering, diminished temperature sensory perception, anddiminished thirst perception. Thus, older clients are at high risk for alterations in ther-moregulation, both hyperthermia and hypothermia.

In addition to the interventions for Adult Health the following can be utilized with the older adult client:



Assist in answering the parent’s or child’s questionsregarding temperature-monitoring procedures oradministration of medications.

Assist the parents in dealing with anxiety in times ofunknown causes or prognosis by allowing [number]minutes per shift for venting anxiety. [State timeshere.] Interview the parents specifically to ascertainanxiety.

Involve the parents and family in the child’s care when-ever appropriate, especially for comforting the child.

Appropriate teaching fosters compliance and reducesanxiety.

Because the emphasis on monitoring and treating alteredthermoregulation is so great, it can be easy to overlookthe parents and their concerns. Specific attention mustbe given to ascertaining how the patient and family arefeeling about all the many concerns generated.

Parental involvement fosters empowerment and regainingof self-care, thereby reestablishing the likelihood foreffective family coping.

Check on older adults often who are at risk:• During heat alerts• During cold weather• In homes without air conditioning or heating• During electrical outages or electrical service interrup-

tions.

Instruct/assist the client to select proper clothing:• Layers during cold weather and lighter garments during

warmer weather.

Monitor and record the temperature of older clients oftenand regularly during high risk times:

• Intra- and postoperative period• When infection is present• When fluid imbalance is present

Use warmed IV solutions in older clients in the intra-/postoperative period unless hyperthermia is present.



Tracks client norms and provides a mechanism for earlyidentification of changes.

Prevent episodes of hypothermia.



TISSUE INTEGRITY, IMPAIRED

DEFINITIONS28

Impaired Tissue Integrity A state in which an individualexperiences damage to mucous membrane, corneal, integu-mentary, or subcutaneous tissue.

Risk for Impaired Skin Integrity A state in whichthe individual’s skin is at risk of being adversely altered.

Impaired Skin Integrity A state in which the indi-vidual has altered epidermis and/or dermis.

Impaired Oral Mucous Membrane Disruptions ofthe lips and soft tissue of the oral cavity.


A. Impaired Tissue Integrity1. Damaged or destroyed tissue (cornea, mucous mem-

brane, integumentary, or subcutaneous)B. Risk for Impaired Skin Integrity*

1. Externala. Radiationb. Physical immobilizationc. Mechanical factors (shearing forces, pressure, and

restraint)d. Hypothermia or hyperthermiae. Humidityf. Chemical substanceg. Excretions or secretionsh. Moisturei. Extremes of age

2. Internal

a. Medicationb. Skeletal prominencec. Immunologic factorsd. Developmental factorse. Altered sensationf. Altered pigmentationg. Altered metabolic stateh. Altered circulationi. Alterations in skin turgor (change in elasticity)j. Alterations in nutritional state (obesity, emaciation)k. Psychogenic

C. Impaired Skin Integrity1. Invasion of body structures2. Destruction of skin layers (dermis)3. Disruption of skin surfaces (epidermis)

D. Impaired Oral Mucous Membrane1. Purulent drainage or exudates2. Gingival recession with pockets deeper than 4 mm3. Enlarged tonsils beyond what is developmentally

appropriate4. Smooth, atrophic, sensitive tongue5. Geographic tongue6. Mucosal denudation7. Presence of pathogens (per culture)8. Difficult speech (dysarthria)9. Self-report of bad taste

10. Gingival or mucosal pallor11. Oral pain or discomfort12. Xerostomia (dry mouth)13. Vesicles, nodules, or papules14. White patches or plaques, spongy patches, or white

curd-like exudate15. Oral lesions, lacerations, or ulcers


••••••


Home Health


Monitor for factors contributing to IneffectiveThermoregulation (illness, trauma, immaturity, aging,or fluctuating environmental temperature).

Involve the client and family in planning, implementing,and promoting reduction or elimination of IneffectiveThermoregulation.

Teach the client and family early signs and symptoms ofIneffective Thermoregulation (see Hyperthermia andHypothermia).

Teach the client and family measures to decrease or elim-inate Ineffective Thermoregulation (see Hyperthermiaand Hypothermia).

Assist the client and family to identify lifestyle changesthat may be required (see Hyperthermia andHypothermia).

Allows early recognition and early implementation oftherapy.

Personal involvement and input increases likelihood ofmaintenance of plan.

Provides basic information and planning to successfullymanage condition at home.

*Risk should be determined by the use of a risk assessment tool(for example, Braden Scale).


Tissue Integrity, Impaired 217

••••••

16. Halitosis17. Edema (gingival or mucosal)18. Hyperemia (“beefy-red”)19. Desquamation20. Coated tongue21. Stomatitis22. Self-report of difficulty eating and/or swallowing23. Self-report of diminished or absent taste24. Bleeding25. Macroplasia26. Gingival hyperplasia27. Fissures, cheilitis28. Red or bluish masses (e.g., hemangioma)

RELATED FACTORS28

A. Impaired Tissue Integrity1. Mechanical (pressure, shear, and friction)2. Radiation (including therapeutic radiation)3. Nutritional deficit or excess4. Thermal (temperature extremes)5. Knowledge deficit6. Irritants7. Chemical (including body excretions, secretions, and

medications)8. Impaired physical mobility9. Altered circulation

10. Fluid deficit or excessB. Risk for Impaired Skin Integrity

The risk factors also serve as the related factors.C. Impaired Skin Integrity

1. Externala. Hyperthermia or hypothermiab. Chemical substancec. Humidityd. Mechanical factors (shearing forces, pressure,

restraint)e. Physical immobilizationf. Radiationg. Extremes of ageh. Moisturei. Medication

2. Internala. Altered metabolic stateb. Skeletal prominencec. Immunologic deficitd. Developmental factorse. Altered sensationf. Alterations in nutritional state (obesity, emaciation)g. Altered pigmentationh. Altered circulationi. Alterations in skin turgor (change in elasticity)j. Altered fluid status

D. Impaired Oral Mucous Membrane1. Chemotherapy2. Chemical (alcohol, tobacco, acidic foods, regular use

of inhalers, drugs, and other noxious agents)

3. Depression4. Immunosuppression5. Aging-related loss of connective, adipose, or bone

tissue6. Barriers to professional care7. Cleft lip or palate8. Medication side effects9. Lack of or decreased salivation

10. Trauma11. Pathologic conditions—oral cavity (radiation to head

or neck)12. NPO status for more than 24 hours13. Mouth breathing14. Malnutrition or vitamin deficiency15. Dehydration16. Ineffective oral hygiene17. Mechanical (ill-fitting dentures, braces, tubes [endo-

tracheal or nasogastric], surgery in oral cavity)18. Decreased platelets19. Immunocompromised20. Impaired salivation21. Radiation therapy22. Barriers to oral self-care23. Diminished hormone levels (women)24. Stress25. Loss of supportive structures


1. Any condition requiring immobilization of patient2. Burns: chemical, thermal, or radiation3. Accidents: motor vehicle, farm equipment, motorcycles,

and so on4. AIDS5. Congestive heart failure6. Diabetes mellitus


Impaired Skin IntegrityIf the tissue damage involves only the skin and itssubcutaneous tissues, then the most correct diagno-sis is Impaired Skin Integrity. Risk for Impaired SkinIntegrity would be the most appropriate diagnosis ifthe patient is presenting a majority of risk factors for askin integrity problem but the problem has not yetdeveloped.

Impaired Oral Mucous MembraneIf the tissue damage involves only the oral mucousmembranes, then the best diagnosis is Impaired OralMucous Membrane. Impaired Tissue Integrity is ahigher-level diagnosis and would cover a wider rangeof tissue types. Impaired Oral Mucous Membrane andthe two diagnoses related to Skin Integrity are morespecific and exact diagnoses and should be usedbefore Impaired Tissue Integrity if the problem can bedefinitively isolated to either the oral mucous mem-brane or the skin.


EXPECTED OUTCOME

Will exhibit structural intactness and normal physiologicalfunction of [skin, mucous membranes, integumentary orsubcutaneous tissues] by [date].

TARGET DATES

Tissue integrity problems can begin developing within hoursof a patient’s admission if caution is not taken regardingturning, cleaning, and so on. Therefore, an initial target dateof 2 days after admission would be most appropriate.


••••••


Adult Health


Ambulate to extent possible.

Perform active or passive ROM at least once per shift at[state times here].

Reduce pressure on affected skin surface by using:• Egg crate mattress• Alternating air mattress• Sheepskin• Commercial wafer barriers• Thick dressing used as pad on bony prominences

Make sure footboard is in place for the patient to use forbracing.

Avoid use of rubber or plastic in direct contact with thepatient.

Collaborate with dietitian regarding well-balanced diet.Assist the patient to eat as necessary.

Monitor dietary intake, and avoid irritant food and fluidintake (e.g., highly spiced food or extremes of temper-ature).

Facilitate fluid intake to at least 2000 mL per 24 hours.

Cleanse perineal area carefully after each urination orbowel movement. Monitor closely for any urinary orfecal incontinence.

Teach the patient principles of good skin hygiene.

Administer oral hygiene at least three times a day aftereach meal and as needed (PRN):

• Brush teeth, gums, and tongue with soft-bristled brush,sponge stick, or gauze-wrapped finger.

• Floss teeth.• Rinse mouth thoroughly after brushing. Avoid commer-

cial mouthwashes and preparations with alcohol,lemon, or glycerin. Use normal saline or oxidizingagent.

Administer medications as ordered and record response(e.g., topical oral antibiotics, analgesic mouthwashes).Record response within 30 minutes of administration.

• Teach the patient and significant others proper oralhygiene.

Stimulates circulation, which provides nourishment andcarries away waste, thus reducing the likelihood of tis-sue breakdown.

Pressure predisposes tissue breakdown.

Prevents tissue breakdown due to negative nitrogenbalance.

These factors would increase probability of oral mucousmembrane problems.

Maintains fluid and electrolyte balance, which is neces-sary for tissue repair and normal functioning.

Allowing body wastes to remain on skin promotes tissuebreakdown. Incontinence would increase probability ofsuch an event.

Promote self-care and self-management to preventproblem.

Basic care measures to maintain oral mucosa.



••••••


• If the patient has dentures, cleanse with equal parts ofhydrogen peroxide and water.

• Apply lubricant to lips at least every 2 hours on[odd/even] hour.

Maintain good body hygiene. Be sure the patient has atleast a sponge bath every day unless skin is too dry.

Monitor for signs of infection at least daily.

Keep room temperature and humidity constant. Roomtemperature should be kept close to 72�F and humidityat a low level unless otherwise ordered.

Teach the patient the impact of smoking on tissues.• Provide information on smoking cessation programs.• Consult with physician to provide nicotine patches and/

or gum as indicated.If lesions develop, cleanse area daily at [time] according

to prescribed regimen.Protect open surface with such products as:• Karaya powder• Skin gel• Wafer barrier• Other commercial skin preparations

Collaborate with an enterostomal therapist and physicianregarding care specific to the patient (list individual-ized care procedures here).

Change dressings when needed using aseptic techniques.Collaborate with health-care team regarding dressingtype and use of topical agents. [Note procedure to beused for client here.]

Teach the patient and significant others care of the woundprior to discharge.

Avoid use of adhesive tape. If tape must be applied, usenonallergenic tape.

Avoid use of doughnut ring.Use mild, unscented soap (or soap substitute) and cool or

lukewarm water.Avoid vigorous rubbing, but do massage gently using a

lanolin-based unscented lotion.Pat area dry.Monitor:• Skin surface and pressure areas at least every 4 hours at

[state times here] for blanching, erythematic, tempera-ture difference (e.g., increased warmth), or moisture.

• Fluid and electrolyte balance. Collaborate with health-care team regarding frequency of measurement of elec-trolyte levels.

Watch for signs or symptoms of edema.Caution the patient and assist to avoid scratching irritated

areas:• Apply cool compresses.

Collaborate with health-care team regarding medicatedbaths (e.g., oatmeal) and topical ointments.

Infection, through production of toxins, wastes, and soon, increases the probability of tissue damage.

Keeps skin cool and dry to prevent perspiration.

Highly irritating to mucous membranes.

Basic care measures for impaired skin integrity.

These measures would allow early detection of any com-plications.

Avoids further irritation of already damaged tissue.




••••••


Adult Health


Collaborate with health-care team regarding adjunct ther-apies (e.g., therapeutic beds, wound closure systems, orbarrier lotions).

Involve physical/occupational therapy in plan of care.

Refer to community health agencies and other health-careproviders as appropriate.

Provides on-going support and cost-effective use of avail-able resources.

Child Health

Utilize adult health interventions with appropriate developmental adaptations with the following considerations.


Handle the infant gently; especially caution paramedicalpersonnel regarding need for gentle handling.

Place the patient on flotation pad, or if the parentschoose, allow the infant or child to be held frequently(avoid placement of infant on any soft surface thatpresents a risk for SIDS).

Caution the patient and parents to avoid scratching irri-tated area:

• Trim nails with appropriate scissors; receive parentalpermission if necessary.

• Make small mitts if necessary from cotton stockinetteused for precasting.

Monitor perineal area for possible allergy to diapers.

Encourage fluids:• Infants: 250 to 300 mL/24 h• Toddler: 1150 to 1300 mL/24 h• Preschooler: 1600 mL/24 h

(These are approximate ranges. The physician may orderspecific amounts according to the child’s age and con-dition.)

Provide protection such as bandage or padding to tissuesite involved.

Monitor and document circulation to affected tissue via:• Peripheral arterial pulses• Blanching or capillary refill• Tissue color• Sensation to touch or temperature• Tissue general condition (e.g., bruising or lacerations)• Drainage (e.g., amount, odor, or color)• OM limitations

The epidermis of infants and young children is thin andlacking in subcutaneous depth. Others, such as x-raytechnicians, may not realize the fragile nature of skinas they carry out necessary procedures.

Alternating surface contact and position favors circula-tory return to central venous system.

Anticipate potential injury of delicate epidermis, espe-cially when irritation may prompt itching.

Various synthetics in diapers may evoke allergenicresponses and either cause or worsen existent skin irri-tation.

Adequate hydration assists in normal homeostatic mecha-nisms that affect the skin’s integrity.

Anticipation and protection from injury serves to limitthe depth and/or degree of impaired skin integrity.

These factors represent basic appropriate criteria for cir-culatory checks. They may be added to in instances ofspecific concerns such as compartment syndrome asso-ciated with hand trauma.



••••••


Administer oral hygiene according to needs and status:• Special orders for postoperative cleft palate or cleft lip

repairTeach the parents to limit time the infant sucks bottle in

reclining position to prevent bottle mouth syndromeand decayed teeth.

Protect the altered tissue site as needed during movementby providing support to the limb.

Provide ROM and ambulation as permitted to encouragevascular return. [Note specific plan for this client here.]

Position the patient while in bed so that the head of thebed is elevated slightly and involved limb is elevatedapproximately 20 degrees.

Address ineffective thermoregulation, and especially pro-tect the patient from chilling or shock due to dehydra-tion or sepsis. Refer to care plans related tothermoregulation for detailed interventions.

Use restraints judiciously for involved limb or body site.

Monitor intravenous infusion and administration of med-ications cautiously. Avoid use of sites in close proxim-ity to area of impaired tissue integrity.

Allow the patient and family time to express concerns byproviding at least [number] minutes per shift for familycounseling. [State times here.]

Teach the patient and family: [Note specific teaching planfor client here.]

• Need for follow-up care• Signs and symptoms to be reported:

• Increased temperature (101�F or higher)• Foul odors or drainage• Delayed healing or increase in damage site size• Loss of sensation or pulsation in limb or site• Any increase in pain

• Use of prosthetic device if indicated• Use of aids in mobility, such as crutches or walker• Need to avoid constrictive clothing• Appropriate dietary needs

Appropriate oral hygiene decreases the likelihood ofaltered integrity of surrounding tissues and is criticalfor care of associated oral disorders.

Evidence suggests that bottle mouth syndrome is pre-vented by not having the infant go to sleep with bottle.Completion of feeding and removal of bottle is sug-gested before placing the infant in crib.

Provision of support and usual use of body parts favoradequate circulation and prevent further injury.

Appropriate venous return is favored by resultant gravitywith limb higher than heart.

In severe instances of ineffective thermoregulation orrelated pathology, there may not be the usual manifes-tations of derivations from normal. It may also be diffi-cult to assess sensation in the young infant because ofthe infant’s inability to provide verbal feedback.

Any undue constriction or threat to circulation must beweighed appropriately in making decisions whether ornot to restrain the child.

This is usual protocol for IV therapy and must be consid-ered paramount as IV medications or solutions poseserious threats to the veins and surrounding tissues.

Reduces anxiety because their concerns can be madeknown and their feelings valued.

Appropriate education serves to build self-confidence andeffects long-term compliance with treatment and healthmanagement.

Women’s Health


Monitor perineum and rectum after childbirth for injuryor healing at least once per shift at [state times here].Monitor episiotomy site for redness, edema, orhematomas each 15 minutes immediately after deliveryfor 1 hour, then once each shift thereafter.

Collaborate with physician regarding:

Assesses basic physical condition as a basis for providingcare and preventing complications.

Provides comfort and promotes healing.(care plan continued on page 222)



••••••


Women’s Health


• Applying ice packs or cold pads to perineum for thefirst 8 to 12 hours after delivery to reduce edema andincrease comfort

• Warm baths twice a day at [state times here] and asnecessary for pain and discomfort

• Analgesics and topical anesthetics as necessary for painand discomfort

Teach good perineal hygiene and self-care:• Rinse perineal area with warm water after each

voiding.• Pat dry gently from front to back to prevent con-

tamination.• Apply perineal pad from front to back to prevent

contamination.• Change pads frequently to prevent infection and

irritation.

Provide factual information on resumption of sexualactivities after childbirth:

• First intercourse should be after adequate healingperiod (usually 3 to 4 weeks).

• Intercourse should be slow and easy (woman on topcan better control angle, depth, and penetration).

Teach postmenopausal women the signs and symptomsof atrophic vaginitis:

• Watery discharge• Burning and itching of vagina or vulva

Encourage examinations (Pap smears) for estrogen levelsat least annually.

In collaboration with physician, encourage use asneeded of:

• Estrogen replacement creams or vaginal suppositories• Extra lubrication during intercourse

Teach breastfeeding mothers about breast care.• Inspect for cracks or fissures in nipples.• Wear supportive bra (breast binder to relieve engorge-

ment).• Shower daily; do not use soap on breast; allow to

air dry.• Use lanolin-based cream (vitamin E cream, Massé

Breast cream, or A and D cream) to prevent dryingand cracking of nipples.

Enhance let-down reflex:• Nurse early and frequently. Ten minutes on each side

is easier on sore nipples than nursing less frequently.• Nurse at both breasts each feeding. Switch sides to

begin nursing each time (e.g., if the baby nursed firston left side at last feeding, begin on right side thistime). A safety pin or small ribbon on bra strap willremind the mother which side she used first last time.

Promotes healing and encourages self-care.

Provides basic information to promote safe self-care.

Provides basic information that promotes self-care andhealth maintenance.

Provides basic information that assists in preventing skinbreakdown and promotes self-care and successful lac-tation.

Promotes let-down reflex and successful breastfeeding.



••••••


• Change positions from one feeding to next (distributessucking pressure).

• Check the baby’s position on breast. Be certain areolais in mouth, not just nipple.

• Begin nursing on least sore side first, if possible, thenswitch the baby to other side.

• Apply ice to nipple just before nursing to decrease pain(fold squares, put them in the freezer and apply asneeded).

Collaborate with the physician regarding analgesics asneeded. Caution the patient to not take over-the-counter medication because some medications arepassed to the baby via breast milk.

Promotes sense of well-being. Assists in promotingproper growth and development of the fetus, andencourages health maintenance.

Provides basic information to the patient that promoteshealth maintenance and increases awareness of needfor self-care.

Prevents X-ray exposure to the fetus.

● N O T E : Between the third and sixth months of pregnancy, the process of tooth calci-fication (hardening) begins in the fetus. What the mother consumes in her diet willaffect the development of the unborn child’s teeth. A well-balanced diet usually pro-vides correct amounts of nutrients for both the mother and the child.

Teach the patient to practice good oral hygiene at leasttwice a day as well as PRN:

• Each time the patient eats and, if nauseated and vomit-ing, vomits, the patient should clean gums and teeth.

• If the smell of toothpaste or mouth rinse makes thepatient nauseated, the patient should use baking soda.

Reduce the number of times sugar-rich foods are eatenbetween meals.

Teach the patient to snack on fruits, vegetables, cheese,cottage cheese, whole grains, or milk.

Have the patient increase daily calcium intake to at leasta total of 1.2 g of calcium per day.

Collaborate with obstetrician and dentist to plan neededdental care during pregnancy.

Assist in planning best time in pregnancy for dentalvisits:

• Not during the first 3 months if:• Previous obstetric history includes miscarriage• Threatened miscarriage• Other medical indications• Hypersensitive to gagging (will increase nausea and

vomiting)• Not during the last 3 months if:

• Not able to sit in dental chair for long periods of time• Obstetric history of premature labor

Instruct the patient to have X-ray examinations onlywhen it is absolutely necessary. Caution the patient torequest a lead apron when having X-ray examinations.


Nursing actions for newborn health immediately followthe Women’s Health nursing actions. As previouslymentioned, newborn actions are included in this sec-tion because newborn care is most often administered




••••••


Women’s Health


by nurses in the obstetric or women’s health area.Focus needs to be made on the newborn simplybecause the newborn’s oral mucous membrane prob-lems can be easily overlooked.

In collaboration with dentist, teach the parents the oraland dental needs of the neonate:

• Use of fluoride• Proper use of pacifiers• Do not use homemade pacifiers• Use pacifiers recommended by dentist• Allowing the infant who is teething to chew on soft

toothbrush (will encourage later brushing of teethbecause it allows the infant to become familiar withtoothbrush in mouth)

• Holding on to brush• Giving brush to the infant only when an adult is present

Teach the parents how to administer oral hygiene:• Massage and rub the infant’s gums with finger daily.• Inspect oral cavity daily for hygiene and problems.

Take the infant for first dental visit between 18 monthsand 2 years of age.

Dental caries (decay) can be a result of prolonged nursingor delayed weaning:

• Do not allow the infant to nurse at breast or bottlebeyond the required feeding time.

• Do not allow the infant to sleep habitually at the breastor with a bottle or pacifier in the mouth.

• Teach the neonate’s parents to:• Avoid giving sweet liquids (soft drinks) or fruit juices

in bottle.• Wean the child from bottle to cup soon after first

birthday.• When continuing to nurse the infant, give water in a

cup soon after the first birthday.• Use good handwashing techniques to prevent infec-

tion with, or reinfection of, thrush.• Not place the infant on sheets where the mother has

been sitting.• Thoroughly clean breast or bottle-feeding equipment.

Promotes good health and provides information as a basisfor parental care of the infant. Assists in preventinginfection.

Mental Health

Plan for adult health can provide the foundation for care with the following considerations:


Refer to Chapter 8 for stress-reduction measures andinterventions for the stressors that produce psy-chogenic skin reactions.



••••••


If the client is placed in restraints, monitor the integrityof skin under restraints every hour.

Apply lanolin-based lotion and cornstarch or powder toarea under restraint at least every 2 hours on[odd/even] hour and PRN.

Pad restraints with nonabrasive materials such as sheep-skin.

Keep the area of restraint next to the skin clean and dry.

Release restraints one at a time every 2 hours on[odd/even] hour and PRN. Remove restraints as soonas the client will tolerate one-to-one care without riskto self or others.

Maintain proper movement and alignment of affectedbody parts.

• Change the client’s position every 2 hours on[odd/even] hour.

• Offer the client fluids every 15 minutes. [List preferredfluids here.]

• While the client is very agitated and physically active,provide constant one-to-one observation.

• While the limb is out of restraints, have the client movethe limb through ROM.

• If the client is in four-point restraints, place him or heron side or stomach and change this position every 2hours on [odd/even] hour.

• Monitor skin condition of pressure areas.• If the client is in four-point restraints, provide one-on-

one observation.• Continually remind the client of reason for restraint

and conditions for having the restraints removed.• Talk with the client in a calm, quiet voice and use the

client’s name.• Use restraints that are wide and have padding. Make

sure padding is kept clean and dry and free of wrinkles.

If Impaired Tissue Integrity is the result of self-harm,place the client on one-to-one observation until the riskof future harm has diminished.

Monitor self-inflicted injuries hourly for the first 24 hoursfor signs of infection can prevent more of infection andfurther damage. Note information on a flow sheet.After the first 24 hours, monitor on a daily basis.

Provide equipment and time for the client to practice oralhygiene at least after each meal.

Discuss with the client lifestyle changes to improve con-dition of mucous membranes, including nutritionalhabits, use of tobacco product, use of alcohol, mainte-nance of proper hydration, and effects of frequentvomiting.

Discuss with the client side effects of medications, suchas antibiotics, antihistamines, phenytoin, antidepres-sants, and antipsychotics that contribute to alterationsin oral mucous membranes.

Lubricates skin and decreases risk for breakdown.

Decreases mechanical friction against the skin, anddecreases risk for breakdown.

Decreases mechanical friction on specific areas for longperiods of time, thus decreasing risk for breakdown.

Hydration improves skin condition.

Promotes circulation and assists in preventing the conse-quences of immobility.

Client safety is of primary importance. This positioningprevents aspiration by facilitating drainage of fluidsaway from the airway.

Provides supportive environment to the client.

Client safety is of primary importance. Provides ongoingsupervision to inhibit impulsive behavior, and encour-ages use of alternative coping behaviors.

Early identification and treatment of infection can preventmore serious damage.

Removes debris and food particles, thus reducing the riskof tissue injury.

Alerts the client to lifestyle patterns that increase risk forinjury to oral mucous membranes. If risk factors arepresent, frequent assessment and increased attention tooral hygiene can decrease the risk of membrane break-down.




••••••


Mental Health


Teach the client to use nonsucrose candy or gum to stim-ulate flow of saliva.

Teach the client to avoid excessive wind and sun expo-sure, especially with antipsychotic drugs.

If the client is taking antipsychotic drugs, suggest the useof a sunscreen containing PABA.

Maintains hydration of membranes and decreases chanceof breakdown.

These medications can cause photosensitivity.38

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized with the aging client


Nursing actions for this diagnosis in the gerontic patientare essentially the same as those for Adult Health andHome Health with the following special notations: Useonly superfatted, nonperfumed, mild, nondetergent, andhexachlorophene-free soap in bathing the patient.98

When drying the skin after bathing, pat the skin dryrather than rubbing, and apply lubricating lotion whilethe skin is still damp.

The incidence of dry skin in the older adult is increasedas a result of decreased production of natural skin oils.

Increases the moisture level of the patient’s skin. Carefulattention to dry skin conditions in the older adult assistsin maintaining tissue integrity for the older adult.


Nursing actions for this diagnosis in the home patient are essentially the same as those for Adult Health and Home Healthwith the following additions:


Assess resources (availability and skill of caregivers,finances, equipment) of client and refer to resources asneeded.94

Arrange interventions to meet identified psychosocialneeds and goals. Follow-up should be planned in coop-eration with the individual and caregiver.94

Set treatment goals consistent with the values andlifestyle of the individual, family, and caregiver.94

For clients who are unable to reposition themselves, care-givers should be taught to use a draw sheet to avoidshearing and skin tears.

• Massage pressure points and bony prominences gentlyat least three times a day. Do not massage reddenedareas.94

Teach patient and caregiver signs and symptoms of tissuebreakdown (e.g., redness over bony prominences, painor discomfort in localized area, skin lesions, or itchingand symptoms that require the attention of a health-care provider).

Prevention of inadequate care and subsequent complica-tions.

Individualized care is more likely to be adopted by clientand caregiver.

Individualized care is more likely to be adopted by clientand caregiver.

Provides data for early intervention and assistspatient/caregiver to know when to seek medical atten-tion.



••••••


Teach measures to promote tissue integrity:• Use mild laundry detergent on clothes. Double-rinse

clothes, linens, and diapers if skin is sensitive.• Use sunscreen to prevent sun damage.• Avoid excessive wind and sun exposure.• Wear properly fitting shoes.

Provides knowledge and skills that will prevent or mini-mize skin breakdown.

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••••••


4ELIMINATION PATTERN1. BOWEL INCONTINENCE 236

2. CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 240

3. DIARRHEA 248

4. READINESS FOR ENHANCED URINARY ELIMINATION 252

5. URINARY INCONTINENCE 254A. ActualB. FunctionalC. ReflexD. StressE. TotalF. UrgeG. Risk for Urge

6. URINARY RETENTION 263


PATTERN DESCRIPTION

The elimination pattern focuses on bowel and bladder func-tioning. Although excretion also occurs through the skin andthe lungs, the primary mechanisms of waste excretion arethe bowel and bladder.

A problem within the elimination pattern may be theprimary reason for seeking health care or may arise second-ary to another health problem, such as impaired mobility.All but a very few of the other patterns or nursing diagnoseswill have an ultimate impact on the elimination pattern fromeither a physiologic, psychological, or sociologic direction.

Included in the elimination pattern are the individual’shabits in terms of excretory regularity, as well as any aidsthe individual uses to maintain regularity or any devicesused to control either bowel or bladder incontinence.

PATTERN ASSESSMENT

1. Is there stool leakage when the client coughs, sneezes,or laughs?a. Yes (Bowel Incontinence)b. No

2. Is there involuntary passage of stool?a. Yes (Bowel Incontinence)b. No

3. Does the client take laxatives on a routine basis?a. Yes (Constipation, Perceived Constipation)b. No

4. Has the number of bowel movements decreased?a. Yes (Constipation)b. No

5. Are stools hard formed?a. Yes (Constipation)b. No

6. Does the client have to strain to have a bowel move-ment?a. Yes (Constipation)b. No

7. Does the client believe he or she is frequently consti-pated?a. Yes (Perceived Constipation)b. No

8. Does the client expect to have a bowel movement at thesame time each day?a. Yes (Perceived Constipation)b. No

9. Are bowel sounds increased?a. Yes (Diarrhea)b. No

10. Has the number of bowel movements increased?a. Yes (Diarrhea)b. No

11. Does the client complain of loose, liquid stools?a. Yes (Diarrhea)b. No

12. Is there increased frequency of voiding?a. Yes (Urinary Incontinence; Stress Incontinence;

Urge Incontinence)b. No (Readiness for Enhanced Urinary Elimination)

13. Is there dribbling of urine when the client laughs,coughs, or sneezes?a. Yes (Stress Incontinence)b. No (Readiness for Enhanced Urinary Elimination)1,2

14. Once need to void is felt, is the client able to reach thetoilet in time?a. Yes (Readiness for Enhanced Urinary Elimination)b. No (Urge Incontinence; Functional Incontinence)

15. Does the client complain of bladder spasms?a. Yes (Reflex Incontinence; Urge Incontinence)b. No (Readiness for Enhanced Urinary Elimination)

16. Is there a decreased awareness of the need to void?a. Yes (Reflex Incontinence; Total Incontinence)b. No (Readiness for Enhanced Urinary Elimination)

17. Is there a decreased urge to void?a. Yes (Reflex Incontinence)b. No (Readiness for Enhanced Urinary Elimination)

18. Does the client void in small amounts?a. Yes (Urge Incontinence; Urinary Retention)b. No (Readiness for Enhanced Urinary Elimination)

19. Is there urine flow without bladder distention?a. Yes (Total Incontinence)b. No

20. Is the bladder distended?a. Yes (Urinary Retention)b. No (Readiness for Enhanced Urinary Elimination)

21. Is there decreased urine output?a. Yes (Urinary Retention)b. No (Readiness for Enhanced Urinary Elimination)


Elimination, simply defined, refers to the excretion of wasteand nondigested products of the metabolic process.Elimination is essential in maintaining fluid, electrolyte, andnutritional balance of the body. A disruption in an individ-ual’s usual elimination pattern can be life-threatening,because a person cannot live long without the ability to ridhis or her body of waste products.2,3

Elimination depends on the interrelated functioning ofthe gastrointestinal system, urinary system, nervous system,and skin. This chapter discusses only the lower urinary tractand gastrointestinal tract; the skin and nervous system arerelated to nursing diagnoses in other chapters. Also, becausethe nursing diagnoses related to elimination refer only toelimination and not the collection and formation of thewaste materials, inclusion of other conceptual informationwould be confusing.

Our society has a dichotomous attitude toward elimi-nation. A great deal of time, effort, and money is expendedin designing and advertising bathrooms and aids to elimi-

230 Elimination Pattern

••••••


nation, but to discuss elimination is considered rude.1

Therefore, obtaining a reliable, complete elimination patternassessment may be difficult. Added to this difficulty is thefact that each person has his or her own normal eliminationhabits and acceptable verbiage around elimination. Elimina-tion is highly individualized and can be influenced by age,circadian rhythms, culture, diet, activity, stress, and a num-ber of other factors. Elimination has elements of bothinvoluntary and voluntary control. The mechanisms thatcontrol the production of waste materials and the neural sig-nals that the bladder or bowel needs to be emptied are pri-marily involuntary. However, each person can usuallycontrol both the timing of bowel and bladder evacuation, aswell as the use of abdominal and perineal muscles to assistin evacuation.

Food and fluid intake are extremely important in elim-ination. A fluid intake of 2000 mL per day and a food intakeof high-fiber foods would, in the majority of instances,ensure an adequate elimination pattern.3,4 Alteration in elim-ination may cause psychosocial problems, such as socialisolation due to embarrassment, as well as physiologic prob-lems, such as fluid and/or electrolyte imbalance.

BOWEL ELIMINATION

The lower gastrointestinal tract includes the small and largeintestines. The small bowel includes the duodenum, jejunum,and ileum, and is approximately 20 feet in length and 1 inchin diameter. The large bowel includes the cecum, colon, andrectum and terminates at the anus. The large bowel isapproximately 5 feet long and 21/2 inches in diameter. Thesmall bowel and large bowel connect at the ileocecal valve.2

The intestines receive partially digested food from thestomach and move the food element through the lower tract,thus assisting in proper absorption of water, nutrients, andelectrolytes. The intestines also provide secretory and stor-age functions. They secrete mucus, potassium, bicarbonate,and enzymes.

The chyme (small intestine contents) is moved byperistalsis, and the feces (large intestine contents) are pro-pelled by mass movements that are stimulated by the gas-trocolic reflex. The gastrocolic reflex occurs in response tofood entering the stomach and causing distention, so massmovement occurs only a few times a day. The gastrocolicreflex occurs within 30 minutes after eating and is predomi-nant after the first meal of the day. Therefore, the time afterthe first meal of the day is the most frequent occurrencebowel elimination. Other reflexes involved in eliminationare the duodenocolic reflex and the defecation reflex. Theduodenocolic reflex is stimulated by the distention of theduodenum as food passes from the stomach to the duode-num. The gastrocolic and duodenocolic reflexes stimulaterectal contraction and, usually, a desire to defecate. Thedefecation reflex occurs in response to feces entering therectum. This reflex promotes relaxation of the internal analsphincter, thus also promoting a desire to defecate. Extra

fluids upon morning waking potentiate the gastrocolicreflex. If the fluids are warm or contain caffeine, they willalso stimulate peristalsis.1,2

The secretions of the gastrointestinal tract assist withfood passage and further digestion. The passage rate of thecontents through the intestines helps determine the absorp-tion amount. The small intestine is responsible for about 90percent of the absorption of amino acids, sodium, calciumchloride, fatty acids, bile salts, and water. Potassium andbicarbonate are excreted. The usual amount of time forchyme to move from the stomach to the ileocecal valvevaries from 3 to 10 hours. It takes approximately 12 hoursfor feces to travel from the ileocecal valve to the rectum.One bowel movement may be the result of meals eaten overthe past 3 to 4 days, but most of the food residue from anyparticular meal will have been excreted within 4 days.Passage of contents is influenced primarily by the amount ofresidue and the motility rate. Feces are normally evacuatedon a moderately regular schedule, but it will vary from threetimes daily to once per week depending on the individual.

When proper absorption does not occur, necessarynutrients and electrolytes are lost for subsequent body use.Small bowel loss can cause metabolic acidosis andhypokalemia. Large bowel loss can lead to dehydration andhyponatremia.

The squatting, leaning forward position is the mostsupportive position for defecation because it increases intra-abdominal pressure and promotes easier abdominal and per-ineal muscle contraction and relaxation. Beside positioning,diet, and fluid intake, other aids to elimination include ene-mas and laxatives.

Enemas assist in evacuation through promotion ofperistalsis, chemical irritation, or lubrication. Volume ene-mas—500 to 1000 mL of fluid—cause distention, whichincreases peristalsis. The addition of heat and soapsuds, forexample, adds chemical irritation and increases peristalsis.Straight tap-water enemas should be used cautiously,because they are hypotonic and may disturb electrolyte bal-ance. Electrolyte enemas are usually prepackaged and arehypertonic. Hypertonic enemas increase fluid amounts inthe bowel through osmosis, thus slightly increasing disten-tion and providing a relatively mild chemical irritation. Boththe distention and irritation also result in increased peristal-sis. Oil enemas are usually small-volume enemas (100 to200 mL) providing lubrication as well as stool softening.1,5

Laxatives assist elimination by producing bulk, pro-viding lubrication, causing chemical irritation, or softeningstool. The action of laxatives ranges from harsh to mild.

Both laxatives and enemas can be abused. Persistentuse of either will diminish normal reflexes so that the indi-vidual will begin to require more and more aid. The individ-ual then establishes an aid-dependent habit just as a drugabuser does.

Although constipation and diarrhea are the two mostcommon problems with bowel elimination, flatulence maybe an associated problem. Flatus (intestinal gas) is normal.


••••••


A problem arises when the individual cannot pass the gasor when abnormally large amounts of gas are produced.Flatus is produced by swallowed air, diffusion of gasesfrom the bloodstream to the gastrointestinal tract, carbondioxide formed by the action of bicarbonate with hydrochlo-ric acid or fatty acids, and bacterial decomposition of foodresidue. Common causes of gas problems include gas-producing foods, highly irritating foods, constipating med-ications such as opioids, and inactivity. The problems relatedirectly to the amount of gas produced and decreased motil-ity. Increased flatus causes distention that, in turn, can causepain, respiratory difficulty, and further problems with intes-tinal motility.1

As previously mentioned, any bowel elimination prob-lem can ultimately be life-threatening. Any bowel elimina-tion problem, whether constipation, diarrhea, or flatulence,that lasts more than 1 to 2 weeks in an adult, or more than 2to 3 days for an infant or elderly person, requires immediatehealth care intervention.

URINARY ELIMINATION

The lower urinary tract is composed of the ureters, bladder,and urethra, which serve as storage and excretory pathwaysfor the waste secreted by the kidneys. The ureters extendfrom the kidney pelvis to the trigone area in the bladder. Theureters are small tubes composed of smooth muscle thatpropels urine by peristalsis from the kidney to the bladder.The bladder stores the urine until it is excreted through theurethra. Between the base of the bladder and the top of theurethra is the urethral sphincter. The sphincter opens underlearned voluntary control. Opening the urethral sphincterallows the urine to pass through the urethra and meatus forelimination. The female urethra is approximately 3 to 5 cen-timeters long, and the male urethra is approximately 20 cen-timeters long.2

In adults, the desire to void occurs when the bladderhas reached a capacity of 250 to 450 mL of urine. As urinecollects to the bladder capacity, the stretch receptors in thebladder muscle are activated. This stretching stimulates thevoiding reflex center in the spinal cord (sacral levels two,three, and four), which sends signals to the midbrain and thepons. These stimuli result in inhibition of the spinal reflexcenter and pudendal nerve, which allows relaxation of theexternal sphincter and contraction of the bladder, and void-ing occurs. The bladder is under parasympathetic control,with the learned voluntary control being guided by the cor-tex, midbrain, and medulla.1,2

The anatomically correct positions for voiding are sit-ting for the female and standing for the male. It is importantto note that in some cultural groups the correct voiding posi-tion for the male is squatting. Either standing or squatting isanatomically correct. Difficulties arise if the male is lyingdown, for example, in traction or a body cast. An individualgenerally voids 200 to 450 mL each voiding time, and it is

within normal limits to void 5 to 10 times per day. Commontimes for urination are on arising and before retiring. Othertimes will vary with habits and correspond with work breaksand availability of toilet facilities.1,2

Urine volume varies according to the individual anddepends on normal kidney functioning, amount of fluid andfood intake, environmental temperature, fluid requirementsof other organs, presence of open wounds, output by otherareas (skin, bowel, or respiration), and medications such asdiuretics. The amount of solutes in the urine, an intact neu-romuscular system, and the action of the antidiuretic hor-mone also influence output. A significant impact on urinaryoutput is the opportunity to void at socially acceptable timesin private.1

Inadequate urinary output may arise from either thekidney not producing urine (suppression) or blockage ofurine flow (retention) somewhere between the kidney andexternal urinary meatus. Suppression may result from dis-ease of the kidneys or other body structures and inadequatefluid intake. Retention may be either mechanical or func-tional in nature. Mechanical retention is due to anatomicblockage, such as a stricture or a calculus. Functional reten-tion refers to any retention that is not mechanical andincludes such areas as neurogenic problems.2

Urinary control relates to the integrity and strength ofthe urinary sphincters and perineal musculature. Inability tocontrol urinary output often leads to social isolation due toembarrassment over control and odor. Urinary incontinenceis more common than most health-care professionals realize.Studies indicate that urinary incontinence is quite commonamong healthy premenopausal middle-aged women.6,7,16

These studies found no relationship between continence sta-tus, number of children, history of gynecologic surgery,smoking, physical activity, or intake of alcohol and caffeine.The studies found also that very few of these women soughttreatment for this incontinence.

Bladder-retraining programs may vary according toindividual hospitals and physicians. Consultation with arehabilitation nurse clinician provides the most current andreliable information regarding a quality bladder-retrainingprogram.8 Two measures that may assist with incontinenceare Credé’s maneuver and the Valsalva maneuver. Credé’smaneuver involves placing the fingertips together at the mid-line of the pelvic crest, then massaging deeply and smoothlydown to the pubic bone. Check with the physician first,because there are contraindications, such as ureteral reflux.5

The Valsalva maneuver involves asking the client to simu-late having a bowel movement. Have the client take a deepbreath, hold it, and then bear down as if expelling feces.Check with the physician first, because there are contraindi-cations, such as glaucoma, eye surgery, and impaired circu-lation.4,5

Urine is a waste product formed as a part of bodymetabolism. Urine is normally produced at a rate of 30 to 50mL per hour. Under normal circumstances, output will bal-


••••••


ance with intake approximately every 72 hours. An hourlyoutput of less than 30 mL, a 24-hour output of 500 mL orless, or an intake–output imbalance lasting longer than 72hours requires immediate intervention.1,3


Elimination depends on the interrelatedness of fluid intake,muscle tone, regularity of habits, culture, state of health, andadequate nutrition.2

INFANT

Kidney function does not reach adult levels until 6 monthsto 1 year of life. Nervous system control is inadequate, andrenal function does not reach a mature status until approxi-mately 1 year of life.2 Voiding is stimulated by cold air. Aninfant usually voids 15 to 60 mL at each voiding during thefirst 24 hours of life and may void reflexively at birth. If theinfant has not voided by 12 hours after birth, there is causefor concern. By the third day, the infant may void 8 to 10times during each 24 hours, equaling about 100 to 400 mL.Urinary output is affected by the amount of fluid consumed,the amount of activity (increased activity equals less urine),and the environmental temperature (increased temperatureequals less urine).9 Uric acid crystals may be found in con-centrated urine, causing a rusty discoloration to the diaper.9

The muscles and elastic tissues of an infant’s intestinesare poorly developed, and nervous system control is inade-quate. Water and electrolyte absorption is functional butimmature. The intestines are proportionately longer than inan adult. Although some digestive enzymes are present, theycan break down only simple foods. These digestive enzymesare unable to break down complex carbohydrates or protein.

Meconium is the first waste material that is eliminatedby the bowel, usually during the first 24 hours of an infant’slife. After 24 hours, the characteristics of the bowel move-ment change as it mixes with milk. The characteristics of thestool depend on whether an infant is breastfed or bottle-fed.The breastfed infant has soft, semiliquid stools that are yel-low or golden in color. The bottle-fed infant has a moreformed stool that is light yellow to brown in color.

An infant may have four to eight soft bowel move-ments a day during the first 4 weeks of life. Flatus oftenaccompanies the passage of stool, and there may be a sourodor to the bowel movement. By the fourth week of life, thenumber of bowel movements has decreased to two to fourper day. By 4 months, there is a predictable interval betweenbowel movements.

It is common for an infant to push or strain at stool.However, if the stools are very hard or dry, the infant shouldbe assessed for constipation. The bottle-fed infant is moreprone to constipation than the breastfed infant is.

Infants sometimes suffer from what is known as colic,described as daily periods of distress caused by rapid, vio-

lent peristaltic waves and increased gas pressure in the rec-tum.9 The cause is unknown but may have to do with thesimple (rather than the complex) digestive enzymes of theinfant or a decreased amount of vitamins A, K, or E. Mostauthorities agree that colic disappears as digestive enzymesbecome more complex and when normal bacterial floraaccumulate.9


By the time the child is 2 years of age, the kidneys are ableto conserve water and to concentrate urine almost on anadult level, except under stress. The bladder increases in sizeand is able to hold approximately 88 mL of urine.

Nervous system and gastrointestinal maturation hasoccurred during infancy and the beginning of the toddleryears. By the time children are 2 to 3 years of age, they areready to control bowel and bladder functioning. Bowel elim-ination control is usually attained first; daytime bladder con-trol is second; and nighttime bladder control is third. Thechild must be able to walk a few steps, control the sphincter,recognize and interpret that the bladder is full, and be ableto indicate that he or she wants to go to the bathroom. Thechild must also value dryness. He or she must recognize thatit is more socially acceptable to be dry than to be wet.

Parents should not attempt toilet training, even if thechild is ready, if there are family or environmental stressors.Regression is normal during toilet training and, coupled withundue stress, could cause physical or psychosocial problems.

Bladder training takes time to accomplish. Both theparent and the child must have patience and not get undulyupset when accidents occur. In fact, nighttime bladder con-trol may not be attained until age 5 to 8 years. Doctorsand researchers disagree on the age at which nighttime bed-wetting (enuresis) becomes a problem.9 Parents should limitfluids at night, have the child void before going to bed, andget the child up at least once during the night to assist inattaining nighttime control.

To toilet train, the parent should watch for patterns ofdefecation. Eating stimulates peristaltic activity and evacua-tion. The child can then be taken to the toilet at the expectedtime after eating. The child should be told what is expectedwhile on the toilet. Give the child enough time to evacuatethe bowel, but do not have the child sit on the toilet too long,as both the child and the parent may become frustrated.

Children at this age like to please their parents. Evac-uation of the bowel is a natural process and should not beapproached as a dirty or unnatural one. The child shouldbe rewarded when able to defecate, but should not be pun-ished if unable to have a bowel movement. Children shouldfeel proud of their accomplishments, and should not be pun-ished or made to feel ashamed for not producing expectedresults.

Children usually do not need enemas or laxatives tomake them regular. In fact, the artificial aids may be dan-


••••••


gerous. Lack of parental understanding of the eliminationprocess and child development, coupled with harsh punish-ment for “accidents,” may lead a child to an obsessive,meticulous, and rigid personality.

Accidents can and do occur even after a child has beencompletely toilet trained, usually because the child ignoresthe defecation urge when he or she is engrossed in an activ-ity and does not want to take the time to go to the bathroom,or when other stressors have a higher priority at that moment.

SCHOOL-AGE CHILD

The urinary system is functioning maturely by this age. Thenormal output is 500 mL per day. Urinary tract infectionsare common in girls because of improper hygiene practices.Girls should be taught to clean the perineum after elimina-tion from front to back to avoid contamination of the urethrawith gastrointestinal flora. The gastrointestinal systemattains adult functional maturity during the school years.School-age children often delay defecation in order to con-tinue with preferred activities such as play or socialization.This delay in defecation often leads to constipation.

ADOLESCENT

There are no noticeable differences in patterns of urinaryelimination in this age group. The intestines grow in lengthand width. The muscles of the intestines become thicker andstronger.

This developmental stage is important in developingbowel habits. The teenager is engaged in developing sexual-ity. This group may ignore warning signals for eliminationbecause they do not want to leave their activities or becauseof the close association of the anus to the teenager’s devel-oping sexual organs. In addition, if a problem arises withelimination, adolescents are reluctant to talk about it witheither their peers or an adult.

YOUNG ADULT

There is no noticeable difference in patterns of eliminationduring this developmental period. Total urinary output for24 hours is 1000 to 2000 mL. The rate of passage of feces isinfluenced by the nature of the foods consumed and thephysical health of the individual. Hemorrhoids are possiblein this developmental group, especially young women.

ADULT

Adequate daily fluid intake helps maintain proper elimina-tion functions. There is a gradual decrease in the number ofnephrons and therefore decreased renal functioning withage. In addition, bladder tone diminishes; thus, the adultmay urinate more frequently.

Digestive enzymes (gastric acid, pepsin, ptyalin, andpancreatic enzymes) also begin to decrease. This may leadto an increasing incidence of intestinal disorders, cancer,and gastrointestinal complaints.

OLDER ADULT

Renal function is slowed by both structural and functionalaging changes, mainly the decrease in the number ofnephrons. Vascular sclerosing also occurs in the renal sys-tem, and this, combined with fewer nephrons, decreasesavailable blood so that the glomerular filtration rate (GFR)becomes markedly reduced. Although the GFR reduction isstill sufficient to handle normal demands, stress or illnesscan significantly alter the older adult’s renal status.10

Decreased concentration and dilution ability of the kidneysoccurs as a result of changes in the renal tubules. Wasteproducts are effectively processed by the kidneys, but over alonger period of time. The decreased efficiency of the kid-neys makes older adults especially vulnerable to medicationside effects and problems regarding drug excretion.2

The older man may have an enlarged prostategland. Obstructive voiding symptoms resulting from prosta-tic enlargement can include hesitancy, decreased forceof stream, terminal dribbling, post void fullness, anddouble voiding.10 Bladder changes, resulting from loss ofsmooth muscle elasticity, can result in decreased bladdercapacity. Uninhibited bladder contractions may interruptbladder filling and lead to a premature urge to void.Increased residual urine and incomplete emptying of thebladder result in a higher incidence of urinary tract infec-tions in older adults of both sexes. Bladder sonography isoften helpful in determining the extent of postvoid residualurine problems.

Changes in the gastrointestinal tract include a contin-ued decrease in digestive enzymes and questionable changesin absorption in the small intestines. The large intestine mayhave reduced blood flow secondary to vascular twisting, andthere is debate regarding decreased motility in the colon.Problems related to constipation may occur as a result ofincreased tolerance for rectal distention rather than decreasedmotility.2

The link between age and constipation is often a resultof many contributing factors, which can include changes influid intake, changes in diet, changes in mobility, environ-mental factors, and health factors. Older adults often drinkless fluid, which slows colonic transit and reduces stool out-put. A decrease in fiber in the diet can lead to slowed colonictransit and decreased frequency of bowel movements.Mobility plays an important role in bowel health, as thehighest risk for constipation is among those who are bed-bound or chairbound.11 Environmental factors such asreduced privacy, inaccessible toileting facilities, inappropri-ate facilities, and reliance on other people for assistance mayalso contribute to the development of constipation.11

Anxiety, depression, and impaired cognition may also con-tribute to the development of constipation. Finally, manymedications can contribute to constipation: opioid anal-gesics, anticholinergics, and antidepressants. Diuretics, hyp-notics, and antipsychotics must be considered in light oftheir effect on genitourinary function.12


••••••



••••••


GORDON’SFUNCTIONAL NANDA NURSING NIC PRIORITYHEALTH PATTERN DIAGNOSIS INTERVENTIONS NOC EVALUATIONS

Elimination Bowel Incontinence

Constipation, Risk for,Actual, Perceived

Diarrhea

Urinary Elimination,Readiness forEnhanced

Urinary Incontinence:Functional

Urinary Incontinence:Reflex

Urinary Incontinence:Stress

Bowel Incontinence CareBowel Incontinence Care:

EncopresisBowel TrainingActualBowel irritationConstipation/Impaction

ManagementPerceivedBowel Management

Risk forConstipation/Impaction

Management

Diarrhea ManagementMedication Management


Prompted VoidingUrinary Habit Training

Urinary Bladder TrainingUrinary Catheterization:

Intermittent

Pelvic Muscle ExerciseUrinary Incontinence Care

Bowel ContinenceBowel EliminationTissue Integrity: Skin & Mucous

MembraneActualBowel EliminationHydrationSymptom ControlPerceivedBowel EliminationHealth BeliefsKnowledge: Health BehaviorRisk forAppetiteBowel EliminationHydrationImmobility Consequences:

PhysiologicalKnowledge: MedicationMedication ResponseMobilityNutritional Status: Food & Fluid

IntakeRisk ControlRisk DetectionSelf-Care: Non-Parenteral

Medication; ToiletingSymptom ControlTreatment Behavior: Illness or InjuryBowel ContinenceBowel EliminationElectrolyte and Acid–Base BalanceFluid BalanceHydrationOstomy Self-CareSymptom SeverityKidney FunctionSelf-Care: ToiletingUrinary ContinenceUrinary EliminationMedication ResponseSelf-Care: ToiletingUrinary ContinenceUrinary EliminationNeurological Status: AutonomicTissue Integrity: Skin & Mucous

MembranesUrinary ContinenceUrinary EliminationUrinary ContinenceUrinary Elimination




BOWEL INCONTINENCE

DEFINITION13

Change in normal bowel habits characterized by involuntarypassage of stool.


1. Constant dribbling of soft stool2. Fecal odor3. Inability to delay defecation4. Urgency5. Self-report of inability to feel rectal fullness6. Fecal staining of clothing and/or bedding7. Recognizes rectal fullness but reports inability to expel

formed stool8. Inattention to urge to defecate9. Inability to recognize urge to defecate

10. Red perianal skin

RELATED FACTORS13

1. Environmental factors (for example, inaccessible bath-room)

2. Incomplete emptying of bowel3. Rectal sphincter abnormality4. Impaction5. Dietary habits6. Colorectal lesions

7. Stress8. Lower motor nerve damage9. Abnormally high abdominal or intestinal pressure

10. General decline in muscle tone11. Loss of rectal sphincter control12. Impaired cognition13. Upper motor nerve damage14. Chronic diarrhea15. Self-care deficit, toileting16. Impaired reservoir capacity17. Immobility18. Laxative abuse


1. Alzheimer’s disease2. Guillain-Barré syndrome3. Spinal cord injury4. Intestinal surgery5. Gynecologic surgery

EXPECTED OUTCOME

Will have no more than one soft, formed stool per day by[date].

TARGET DATES

Target dates should be based on the individual’s usual bowelelimination pattern. Incontinence may require additionalretraining time and effort. Therefore, a target date 5 daysfrom admission would be most realistic. Also remember that


••••••


GORDON’SFUNCTIONAL NANDA NURSING NIC PRIORITYHEALTH PATTERN DIAGNOSIS INTERVENTIONS NOC EVALUATIONS

Urinary Incontinence:Total

Urinary Incontinence:Urge

Urinary Incontinence:Urge, Risk for

Urinary Retention

Urinary Incontinence Care

Urinary Habit TrainingUrinary Incontinence Care

Urinary Habit Training

Urinary CatheterizationUrinary Retention Care

Tissue Integrity: Skin & MucousMembrane

Urinary ContinenceUrinary EliminationSelf-Care: ToiletingUrinary ContinenceUrinary EliminationInfection SeverityKnowledge: Medication; Treatment

RegimenMedication ResponseNeurological Status: AutonomicRisk ControlRisk DetectionStress LevelUrinary ContinenceUrinary EliminationUrinary ContinenceUrinary Elimination


Bowel Incontinence 237

••••••

there must be a realistic potential that bowel continence canbe regained by the client.

4Have You Selected the Correct Diagnosis?

ConstipationThe problem may really be due to constipation withimpaction. Incontinence may occur because somefeces are leaking around the impaction site and theindividual is unable to control its passage and thusappears incontinent.

Self-Care Deficit, ToiletingIf the individual is unable to appropriately care for hisor her evacuation needs, incontinence may result.

DiarrheaDiarrhea relates to frequent bowel movements, butthe client is aware of rectal filling and can control thefeces until reaching the toilet. With incontinence, theclient may not be aware of rectal filling, and the stoolpassage is involuntary.

NURSING ACTIONS/INTERVENTIONS AND RATIONALES

Adult Health


Impaction may lead to leakage of bowel contents aroundimpacted area.12,14

Assists in determining the pattern of incontinence.

Assists in determining the pattern of incontinence.

Allows early detection of any tissue integrity problems.

Bowel contents are damaging to the skin and predisposethe patient to tissue integrity problems.

The patient may find incontinence embarrassing and maytry to isolate self.

Establishes consistent pattern, and conditions control ofelimination.

Basic knowledge promotes understanding of conditionand assists the patient to change behavior as well asempowering the patient for self-care.

Strengthens pelvic floor and abdominal muscles.

Check for fecal impaction on admission, and implementnursing actions for constipation if impaction is noted.

Record each incontinent episode when it occurs as wellas the amount, color, and consistency of each stool.

Record events associated with the incontinent episode,including events both before and after the episode (i.e.,activity, stress, location, people present, etc.).

Scrutinize and/or remove factors that contribute to incon-tinent episodes (e.g., stress, diet, problems in accessi-bility to bathroom).

Examine perianal skin integrity following each inconti-nent episode.

Keep the anal area clean and dry.

Provide emotional support for the patient through teach-ing, providing time for listening, etc.

Initiate bowel training at least 4 days before discharge:• Suppository 30 minutes after eating.• Toilet half-hour after suppository insertion.• Toilet prior to activity.• Stimulate defecation reflex with circular movement in

rectum using gloved, lubricated finger.

Teach the client, beginning as soon after admission aspossible:

• Pelvic floor muscle exercises, alternating contrac-tion and relaxation of perineal muscles while sittingin a chair and with feet placed apart on floor[Note schedule to talk client through these here.]

• Diet (i.e., role of fiber and fluids)• Use of assistive devices such as Velcro closings on

clothes, pads• Perineal hygiene• Appropriate use of suppositories and antidiarrheal med-

ications

Refer for home health-care assistance.(care plan continued on page 238)



••••••

NURSING ACTIONS/INTERVENTIONS AND RATIONALES (continued from page 237)

Child Health

Nursing actions for bowel incontinence in the child are essentially the same as those for Adult Health, plus the following.Modifications need to be made for child’s age and size (e.g., medication dosage and fluid amounts). Encopresis is the termnoted in the literature, with a prerequisite factor identified to be that the event must occur at least once a month for at least3 months, and the chronological or developmental age of the child must be at least 4 years.


Assess for contributory factors, especially environmentalchange such as a new home, birth of sibling, or changein bathrooming environment.

Note related abnormalities of the digestive tract includingleakage secondary to bowel obstruction in infants orHirschsprung’s syndrome of mega-colon or relatedbowel obstruction with leakage.

Assess for related medical conditions such asmyelomeningocele, cerebral palsy, or hypothyroidism.

For instances of pattern of fear–pain cycles of encopresis,assess for possible disturbance in the mother–childrelationship.

Assess for stressors in the family or child’s daily routine.

Obtain a full history in order to individualize the plan ofcare. Identify related circumstantial factors and encour-age the parents to share their thoughts regarding theproblem.

Maintain a nonjudgmental attitude throughout.

Allow for embarrassment according to age when child isexpected to be self-toileting.

Provide appropriate emotional support for child andfamily.

Allows for fullest consideration of possible etiology forthe problem of bowel incontinence.

Allows for fullest consideration of possible etiology forthe problem of bowel incontinence.

Ensures consideration for fullest possible etiology ofproblem of bowel incontinence.

Emotional factors may contribute to the pattern.

Stress contributes to altered bowel pattern.

Offers individualized plan of care with attention to pri-mary factors.

Fosters open communication.

Communicates caring and nonjudging of behaviors.

Offers validation of the importance of being accepted byothers and how this is threatened.

Women’s Health

Nursing actions and interventions in bowel incontinence in Women’s Health are the same as in Adult Health, except forthe following:

Mental Health


If a pattern forms around specific events, develop plan to:• Remind the person to use the bathroom before the

event. Add positive reinforcers as they remember ontheir own. [Note reinforcers to be used here.]

Promotes the client’s perceived control, and increasespotential for the client’s involvement in treatmentplan.17

As women age and estrogen levels decrease, the perinealfloor sometimes loses elasticity, which can lead to con-stipation and/or bowel incontinence if proper diet andexercise are not practiced.

Encourage women to discuss with the health careprovider any problems with changes in bowel habits.Many women will not discuss these problems becauseof embarrassment.16

Many women who have suffered uterine prolapse andpelvic relaxation with displacement of pelvic organscan be relieved only by surgical repair.15


Bowel Incontinence 239

••••••

Mental Health


• Alter the manner in which a specific task is performedto prevent stress. [Note alterations here.]

• Discuss with the client alternative ways of copingwith stress. (Refer to Chapter 8 for specific nursingactions related to reduction of anxiety, and Chapter11 for specific nursing actions related to ineffectivecoping.)

If assessment suggests secondary gains associated withepisodes, decrease these by:

• Withdrawing social contact after an episode• Having the client clean him- or herself• Providing social contact or interactions with the client

at times when no incontinence is experienced

If not related to secondary gain, spend [number] minuteswith the client after each episode to allow expressionof feelings.

Discuss with the client the effects this problem has on hisor her lifestyle.

Provides negative consequences for inappropriate copingbehavior.18

Verbalization of feelings in a nonthreatening environmentmodels acceptance of feelings and positive copingbehavior.18

Increases the client’s awareness of impact inappropriatecoping behaviors have on lifestyle. Provides data fordevelopment of alternative coping, promoting theclient’s perceived control.19

Gerontic Health

l N O T E : Incontinence is not a normal part of aging. When older adults experienceincontinence, efforts should be made to both determine the cause of the incontinence andreturn the client to a continent state.



Record events associated with incontinent episode.

Monitor medication intake for potential to result in bowelincontinence.

Teach toileting skills to caregivers of cognitivelyimpaired older adults. In early dementia, labeling thebathroom and reminding the individual to toilet mayresult in continence.

Assists in determining the pattern of incontinence. Olderadults may have difficulty in reaching the commode orbathroom easily.

Medications with a sedative effect may decrease the abil-ity of the client to reach toilet facilities in a timelymanner.

Depending on the stage of the disease, a person withdementia may forget to toilet or have difficulty findinga bathroom that is not readily identified.

Home Health

Nursing actions for incontinence in the Home Health setting are the same as those for Adult Health, with the followingadditions:


Assist the client/family in identifying factors that may becontributing to the problem:

Diarrhea is a common cause of bowel incontinence.Promotes understanding of the condition and may leadto solutions.




••••••


Home Health


• Diarrhea• Diet• Medications• Environmental issues• Fatigue• Difficulty removing clothes

Modify the home environment as needed to facilitate con-tinence as appropriate:

• Clear the path to the bathroom.• Provide bedside commodes as needed.

Educate the client/family on the correct use of antidiar-rheal agents as needed to reduce the frequency ofbowel movements.

Monitor skin integrity for skin breakdown.

Educate the client/family regarding the need to keep bedlinens and clothing clean and dry

Assess the client/family need for adult diapers, linens.Make referrals for obtaining these supplies asappropriate.

Diarrhea is a common cause of bowel incontinence.

These measures prevent secondary problems from occur-ring as a result of the existing problem.

These measures prevent secondary problems fromoccurring as a result of the existing problem.


CONSTIPATION, RISK FOR,ACTUAL, AND PERCEIVED

DEFINITIONS13

Constipation A decrease in a person’s normal frequencyof defecation accompanied by difficult or incomplete pas-sage of stool and/or passage of excessively hard, dry stool.

Risk for Constipation At risk for a decrease in aperson’s normal frequency of defecation accompanied bydifficult or incomplete passage of stool and/or passage ofexcessively hard, dry stool.

Perceived Constipation The state in which an indi-vidual makes a self-diagnosis of constipation and ensuresa daily bowel movement through abuse of laxatives, enemas,and suppositories.


A. Constipation1. Change in bowel pattern2. Bright red blood with stool3. Presence of soft paste-like stool in rectum4. Distended abdomen5. Dark or black or tarry stool

6. Increased abdominal pressure7. Percussed abdominal dullness8. Pain with defecation9. Decreased volume of stool

10. Straining with defecation11. Decreased frequency12. Dry, hard, formed stool13. Palpable rectal mass14. Feeling of rectal fullness or pressure15. Abdominal pain16. Unable to pass stool17. Anorexia18. Headache19. Change in abdominal growling (borborygmi)20. Indigestion21. Atypical presentation in older adults (e.g., change in

mental status, urinary incontinence, unexplainedfalls, elevated body temperature)

22. Severe flatus23. Generalized fatigue24. Hypoactive or hyperactive bowel sounds25. Palpable abdominal mass26. Abdominal tenderness with or without palpable

muscle resistance


27. Nausea and/or vomiting28. Oozing liquid stool

B. Risk for Constipation (Risk Factors)1. Functional

a. Habitual denial or ignoring of urge to defecateb. Recent environmental changesc. Inadequate toileting (e.g., timeliness, positioning

for defecation, privacy)d. Irregular defecation habitse. Insufficient physical activityf. Abdominal muscle weakness

2. Psychologicala. Emotional stressb. Mental confusionc. Depression

3. Physiologica. Insufficient fiber intakeb. Dehydrationc. Inadequate dentition or oral hygiened. Poor eating habitse. Insufficient fluid intakef. Change in usual foods and eating patternsg. Decreased motility of gastrointestinal tract

4. Pharmacologica. Phenothiazinesb. Nonsteroidal anti-inflammatory agentsc. Sedativesd. Aluminum-containing antacidse. Laxative overdosef. Iron saltsg. Anticholinergicsh. Antidepressantsi. Anticonvulsantsj. Antilipemic agentsk. Calcium channel blockersl. Calcium carbonatem. Diureticsn. Sympathomimeticso. Opiatesp. Bismuth salts

5. Mechanicala. Rectal abscess or ulcerb. Pregnancyc. Rectal anal strictured. Postsurgical obstructione. Rectal anal fissuresf. Megacolon (Hirschsprung’s disease)g. Electrolyte imbalanceh. Tumorsi. Prostate enlargementj. Rectocelek. Rectal prolapsel. Neurologic impairmentm. Hemorrhoidsn. Obesity

C. Perceived Constipation1. Expectation of a daily bowel movement with the resu-

lting overuse of laxatives, enemas, and suppositories.2. Expected passage of stool at same time each day.

RELATED FACTORS13

A. Constipation1. Functional

a. Habitual denial or ignoring of urge to defecateb. Recent environmental changesc. Inadequate toileting (e.g., timeliness, positioning

for defecation, privacy)d. Irregular defecation habitse. Insufficient physical activityf. Abdominal muscle weakness

2. Psychologicala. Emotional stressb. Mental confusionc. Depression

3. Physiologica. Insufficient fiber intakeb. Dehydrationc. Inadequate dentition or oral hygiened. Poor eating habitse. Insufficient fluid intakef. Change in usual foods and eating patternsg. Decreased motility of gastrointestinal tract

4. Pharmacologica. Phenothiazinesb. Nonsteroidal anti-inflammatory agentsc. Sedativesd. Aluminum-containing antacidse. Laxative overdosef. Iron saltsg. Anticholinergicsh. Antidepressantsi. Anticonvulsantsj. Antilipemic agentsk. Calcium channel blockersl. Calcium carbonatem. Diureticsn. Sympathomimeticso. Opiatesp. Bismuth salts

5. Mechanicala. Rectal abscess or ulcerb. Pregnancyc. Rectal anal strictured. Postsurgical obstructione. Rectal anal fissuresf. Megacolon (Hirschsprung’s disease)g. Electrolyte imbalanceh. Tumorsi. Prostate enlargement

Constipation, Risk for, Actual, and Perceived 241

••••••


j. Rectocelek. Rectal prolapsel. Neurologic impairment

m. Hemorrhoidsn. Obesity

B. Risk for ConstipationThe risk factors are also the related factors.

C. Perceived Constipation1. Impaired thought processes2. Faulty appraisal3. Cultural or family health belief


1. Anemias2. Hypothyroidism3. Hemorrhoids4. Renal dialysis5. Abdominal surgery

EXPECTED OUTCOME

Will return, as nearly as possible, to usual bowel eliminationhabits by [date].

TARGET DATES

Target dates should be based on the individual’s usual bowelelimination habits. A target date 3 to 5 days from admissionwould be reasonable for the majority of clients.


Imbalanced Nutrition, Less orMore Than Body RequirementsThis might be the primary nursing diagnosis. Either ofthese diagnoses influences the amount and consis-tency of the feces.


••••••

Deficient Fluid VolumeThis diagnosis might also be the primary problem. Thefeces need adequate lubrication to pass through thegastrointestinal tract. If there is a Deficient FluidVolume, the feces is harder, more solid, and unable tomove through the system.

Diarrhea or Bowel IncontinenceConstipation can be misdiagnosed as Diarrhea orBowel Incontinence. Diarrhea or incontinence maybe a secondary condition to constipation, as semi-liquid feces may pass around the area of constipa-tion.

Impaired Physical MobilityThis diagnosis could be the underlying cause of con-stipation. Decrease in physical mobility affects everybody system. In the gastrointestinal tract, peristalsis isslowed, which may lead to a backlog of feces and toconstipation.

Self-Care Deficit, ToiletingThis diagnosis may also be the primary diagnosis.Difficulty in reaching appropriate toileting facilities anddifficulty in cleansing oneself after toileting could leadto a decision to delay bowel movement, with a resultof constipation.

Ineffective Individual Coping and AnxietyThese diagnoses are two psychosocial nursing diag-noses from which Constipation needs to be differenti-ated. Both of these psychosocial diagnoses initiatestress as an autonomic response, and the parasympa-thetic system stimuli (which control motility of thegastrointestinal tract) are reduced. This reduced motil-ity may lead to constipation.


Adult Health


Record amount, color, and consistency of feces followingeach bowel movement. Question the client regardingbowel movements at least once per shift. Also record ifthere was no bowel movement on each shift.

Monitor and record symptoms associated with passage ofbowel movement:

• Any straining, pain, or headache• Any rectal bleeding or fissures

If fecal impaction:

Basic assessment of problem severity as well as monitor-ing effectiveness of therapy.

Allows early detection of additional problems.

Prioritization of methods used to break up and removeimpaction.



••••••


• Attempt digital removal using gloves and lubrication.• Administer oil retention enema of small volume.

Have the client retain for at least 1 hour.5

• Use small-volume saline enema if oil retention doesnot relieve impaction.

Collaborate with appropriate members of health-careteam regarding additional pharmacological strategies(e.g., stool softeners, laxatives, etc.).

Measure and total intake and output every shift.

Force fluids, of client’s choice, to at least 2000 mL daily.Provide 8 ounces of fluid every 2 hours on [odd/even]hour beginning at awakening each morning. [Noteclient’s preferred fluids here.]

Increase the client’s activity to extent possible throughambulation at least three times per day while awake.[Note schedule here.]

Assist the client with implementation of stress reductiontechniques at least once per shift. [Note technique to beused and schedule here.]

Digitally stimulate the anal sphincter at scheduled times(usually after meals) [State times here].

Provide privacy and sufficient time for bowel elimination.

Help the client assume positions that facilitate bowelmovements (e.g., a forward leaning position while sit-ting, or a semi-Fowler’s position if on a bedpan).20

Monitor anal skin integrity at least once per shift.

Teach the client, starting as soon after admission aspossible:

• Pelvic floor muscle exercises• The importance of a bowel routine and the need to

respond to the urge to defecate as soon as possible• To stimulate gastrocolic reflex through drinking prune

juice or hot liquid on arising• To allow sufficient time for bowel movement and plan

time for elimination• To include high-fiber foods and adequate liquid in

daily diet• To avoid prolonged use of elimination aids such as

laxatives and enemas• To avoid straining• To use proper perineal hygiene• To describe the relationship of diet and activity to

bowel elimination

Collaborate (as deemed necessary), with the following assoon as possible after admission:

• With the dietitian, regarding a high-fiber, high-roughage diet (the more food a client eats, the less lax-atives the client will require)

• With the physical therapist, regarding exercise program

Allows monitoring of adequate fluid intake to increasewater content of feces.

Increases moisture and water content of feces for easiermovement through intestines and anus.

Activity promotes stimulation of the bowel and assists inelimination.

Promotes relaxation and can increase feces passagethrough the intestines.

Stimulates defecation reflex and urge.

Decreases stress and promotes relaxation, whichincreases likelihood of bowel movement.

Promotes effective use of abdominal muscles, and allowsgravity to assist in defecation.

Straining at stool can cause splits and tears of the analtissue.

Promotes understanding of self-care needs prior to dis-charge.21


Provides basic resources and information needed; pro-motes holistic approach to treatment.




••••••


Adult Health


• With the health-care provider, regarding mild anal-gesics and ointments for control of pain associated withbowel movements

• With the health-care provider, regarding use of stoolsofteners, laxatives, suppositories, and enemas

• With the enterostomal therapist, regarding ostomy care(i.e., irrigations, stoma and skin care, and appliances)

• With the psychiatric nurse clinician, regarding counsel-ing for the client and family about possible underlyingemotional components

• With the home health nurse, regarding follow-up plan-ning for home and usual daily activities of living withemphasis on stress, etc.

Child Health

Nursing actions for constipation in the child are essentially the same as those for Adult Health. Modifications wouldbe made for child’s age and size, for example, medication dosage and fluid amounts. For the diagnosis of Risk forConstipation, the following actions would be appropriate:


Monitor for all possible contributory factors including:• Hirschsprung’s disease (congenital aganglionic

megacolon)• Neonatal period:

• Failure to pass meconium in first 24 to 48 hours afterbirth

• Reluctance to ingest fluids• Bile-stained vomitus• Abdominal distention• Intestinal obstruction

• Infancy:• Inadequate weight gain• History of constipation• Abdominal distention• Episodic diarrhea and vomiting• Bloody diarrhea• Fever• Severe lethargy

• Childhood:• Constipation• Ribbon-like, foul-smelling stools• Abdominal distention• Palpable fecal masses• History of poor appetite, poor growth

Monitor for contributing factors according to likelihoodof potential for age, diet, known medical status, anddevelopmental crisis (e.g., iron in infant formula, vita-mins, known hypothyroidism, self-toileting, etc.).

Appropriate identification of cause of constipation incase of Hirschsprung’s disease will offer appropriatetreatment.

Developmentally appropriate factors will assist inidentification of likely essential issues.



••••••

Women’s Health

Nursing actions for constipation in women are essentially the same as those for Adult Health, except for the following con-siderations during pregnancy:


Assist the client in identifying lifestyle adjustments thatmay be needed because of changes in physiologicfunction, or needs during experiential phases of life(e.g., during pregnancy, postpartum, and followinggynecologic surgery).

Teach the client changes that occur during pregnancy thatcontribute to decreased gastric motility and potentialconstipation:

• Fluid intake may decrease because of nausea and vom-iting of early pregnancy.

• Increased use of mother’s body fluid intake to pro-duce lactation can lead to decrease in fluid intakeoverall.

• Supplemental iron during pregnancy can lead to severeconstipation.

• Fear of injury or pain upon defecation after birth canlead to constipation.

Teach anatomic shifting of abdominal contents becauseof fetal growth.

Teach hormonal influences (e.g., increased progesterone)on bodily functions:

• Decreased stomach emptying time• Decreased peristalsis• Increase in water reabsorption• Decrease in exercise• Relaxation of abdominal muscles• Increase in flatulence

Teach the effects of the increase in oral iron or calciumsupplements on the gastrointestinal tract (e.g., consti-pation).

Describe the physical changes present in the imme-diate postpartum period that affect the gastrointesti-nal tract:

• Lax abdominal muscles• Fluid loss (perspiration, urine, lochia, or dehydration

during labor and delivery)• Hunger

Assist the client in planning diet that will promote heal-ing, replace lost fluids, and help with return to normalbowel evacuation.

Instruct in the use of ointments, anesthetic sprays, sitzbaths, and witch hazel compresses to relieve epi-siotomy pain and reduce hemorrhoids.

Instruct in pelvic floor exercises (Kegel exercises) toassist healing and reduction of pain.

Teach nursing mothers alternate methods of assistancewith bowel evacuation other than cathartics (catharticsare expressed in breast milk).

Provides information needed as basis for planning careand health maintenance.

Provides basic information for self-care during preg-nancy, birthing process, and postpartum.22

Provides information as a basis for nutrition plan duringpregnancy. Promotes self-care.

Provides basis for teaching the client plan of self-careat home, and promotes healing process.

Promotes successful lactation, good self-care, and goodnutrition, and provides basis for teaching care.




••••••


Women’s Health


• Prune juice• Hot liquids• High-fiber, high-roughage diet• Daily exercise

Describe the physical changes present in the imme-diate postoperative period (cesarean section andgynecologic surgery) that affect the gastrointestinaltract:

• Fluid loss (blood loss or dehydration as a result ofNPO [nothing by mouth] status and surgery)

• Decreased peristalsis• Bowel manipulation during surgery• Increased use of analgesics and anesthesia

During pregnancy:

• Encourage women to drink sufficient fluids (at leasteight glasses per day).

• Establish regular schedule for bowel movements.• Encourage a balanced diet with appropriate amounts of

fiber, fruits, and vegetables.

During pregnancy the bowel is misplaced by the growinguterus and this can lead to changes in bowel elimina-tion and function.

During the postpartum period the combination of medica-tions used in labor and delivery, a hectic schedule, lackof sleep, as well as preoccupation with a new baby,lead to changes in elimination patterns.

Provides basis for teaching and planning of care.Promotes and encourages self-care.

Gastrointestinal tract motility slows because of hormones(particularly progesterone) and increased growth ofuterus. Greater absorption of water causes drying ofstool.

Constipation can be avoided by increasing fluids and fiberin the diet and regular exercise.16

Education and nutritional counseling should focuson dietary advice to ensure the new mother is drink-ing sufficient fluids and including roughage in herdiet.22

The above is especially true during the postpartum periodand when breastfeeding.22

Mental Health

Clients taking antipsychotics, antianxiety agents, and antidepressants are at risk for this diagnosis.23 The nursing actionsfor Mental Health are the same as those for Adult Health. Please refer to those recommended actions.

Gerontic Health


Review medication record for drugs that may have consti-pation as a side effect.

Older adults receiving opioid analgesics, antidepressants,anticholinergics, or certain antacids may experienceconstipation due to the drug-delayed motility of wastematter through the intestine. Older adults are morelikely to be on multiple medications that can result inconstipation.



••••••

Gerontic Health


Collaborate with the physician regarding changes in med-ication to avoid the side effect of constipation.

Collaborate with the client to increase their mobility asappropriate through:

• Consultation with physical therapy• Chair exercises

Collaborate with client and caregivers to increase fluidand fiber intake. Caution should be taken to increasefiber only when fluids are tolerated well.

Use bulking agents with care in the aging client.

Encourage the client to establish effective bowel habits:• Taking advantage of the gastro-colic reflex but toileting

after meals• Toileting at a regular time each day• Ensuring that the toilet is the correct height, using seat

raisers as needed.

Assist the client to maintain adequate toileting facilities:• Privacy during toileting• Toilet at the correct height• Assistance with mobility as needed• Facilities to call for assistance to access toilet

Lack of exercise is associated with slowed bowel motility.

Increased fluid and fiber prevent constipation. Increasedfiber in the absence of adequate fluid consumption canlead to increased incidence of fecal impaction, particu-larly in immobile clients.

Increased fiber in the absence of adequate fluid consump-tion can lead to increased incidence of fecal impaction,particularly in immobile clients.

These habits minimize the risk of constipation.11

These habits minimize the risk of delayed emptyingwhich leads to constipation.11

Home Health

l N O T E : Nursing actions for constipation in the Home Health setting are the same asthose for Adult Health. The locus of control shifts from the nurse to the client, family,and/or caregiver.


The nurse will teach others to complete activities.

Teach the client and family the definition of constipation.Determine whether the problem is perceived by theclient and family because of incorrect definition or isbased on physiologic dysfunction.


• Establishment of a regular elimination routine based oncultural and individual variations

• Stress management techniques• Decrease in concentrated, refined foods• Identification of any food intolerances or allergies and

avoidance of those foods• Appropriate use and frequency of use of prescribed and

over-the-counter medications• Physiologic parameters of constipation

The client and members of the family may have differentideas regarding appropriate elimination patterns.

Nursing interventions for physiologic definition are out-lined in the Adult Health nursing action. Nursing inter-ventions for varying definitions require familyinvolvement.

Home-based care requires involvement of the family.Bowel elimination problems may require adjustmentsin family activities.



••••••

DIARRHEA

DEFINITION13

Passage of loose, fluid, unformed stools.


1. Hyperactive bowel sounds2. At least three loose stools per day3. Urgency4. Abdominal pain5. Cramping

RELATED FACTORS13

1. Psychologicala. High stress levels and anxiety

2. Situationala. Alcohol abuseb. Toxinsc. Laxative abused. Radiatione. Tube feedingsf. Adverse effects of medicationg. Contaminantsh. Travel

3. Physiologica. Inflammationb. Malabsorptionc. Infection processd. Irritatione. Parasites


1. Inflammatory bowel disease (ulcerative colitis, Crohn’sdisease, enteritis)

2. Anemias3. Gastric bypass or gastric partitioning surgery4. Gastritis

EXPECTED OUTCOME

Will return to usual bowel elimination habits by [date].

TARGET DATES

Target dates should be based on the individual’s usual bowelelimination habits. Thus, a target date 3 days from the dayof admission would be reasonable for the majority of clients.Because diarrhea can be particularly life-threatening forinfants and older adults, a target date of 2 days would not betoo soon.


ConstipationDiarrhea may be secondary to constipation. Ininstances of severe constipation or impaction, semi-liquid feces can leak around the areas of impactionand will appear to be diarrhea.

Imbalanced Nutrition, LessThan Body RequirementsIf the individual is not ingesting enough food or suffi-cient bulk to allow feces to be well formed, diarrheamay well result.

Deficient Fluid Volume or Excess Fluid VolumeAlthough research has not definitely supported theimpact of fluid volume on bowel elimination, it is com-mon practice to pay attention to these diagnoseswhen either constipation or diarrhea is present. Thegeneral notion appears to be that the amount of fluidingested or absorbed by the body can affect the con-sistency of the fecal material.

Anxiety, Self-Esteem Disturbance,or Ineffective Individual CopingAny of these psychosocial diagnoses precipitate astress response. Indices of stress include gastroin-testinal signs and symptoms (e.g., diarrhea, vomiting,and “butterflies” in the stomach).

Disturbed Sleep PatternIf a person’s biologic clock is changed because ofaltered sleep–wake patterns, body responses attunedto the biologic clock will also be altered. This includesusual elimination patterns, and diarrhea may result.


Adult Health


List here those foods that the patient has described asbeing irritating.

Record amount, color, consistency, and odor followingeach bowel movement.

Monitor weight and electrolytes at least every 2 dayswhile diarrhea persists. [State dates here.]

Basic monitoring of conditioning as well as monitoringof effectiveness of therapy.

Monitors fluid and electrolyte status.


Diarrhea 249

••••••


Measure and total intake and output every shift.Provide oral intake of fluids and bland food.

Ensure the client can easily access bathroom facilities orbedside commode.

Administer antidiarrheal medications as prescribed anddocument results within 1 hour after administration.For example, diarrhea decreased from one stool every30 minutes to one stool every 2 hours.25

Increase fluid intake to at least 2500 mL per day.Offer fluids high in potassium and sodium at least once

per hour (e.g., sports drinks).Serve fluids at tepid temperature (avoid temperature

extremes).List the client’s fluid likes and dislikes here.Provide perineal skin care after each bowel movement.

Inspect perianal skin integrity after each bowelmovement.

If tube feedings are a causal factor, collaborate with theappropriate health-care provider regarding optimalenteral therapy.

Assist the client with stress reduction exercises at leastonce per shift; provide quiet, restful atmosphere. [Noteexercises to be used and schedule here.]

Collaborate with the dietitian regarding low-fiber, low-residue, soft diet.

List here those foods that the client has described asbeing irritating.

Teach the client:• Diet: avoiding irritating foods, including basic food

pyramid groups, influence of high-fiber foods, andinfluence of fruits.

• Fluids: maintaining intake and output balance, influ-ence of environmental temperature, influence of activ-ity, and influence of caffeine and milk.

• Medications: caution with over-the-counter medica-tions, those that are antidiarrheal, and those that poten-tiate diarrhea (e.g., antacids and antibiotics).

Monitors hydration status.Fluid intake will assist in maintaining adequate fluid bal-

ance. Bland foods will avoid bowel stimulation.Helps prevent accidents and prevent embarrassment for

the client.Documents effectiveness of medication.

Maintains hydration status.Replaces or maintains electrolytes lost with diarrhea.

Fluids at temperature extremes can stimulate the bowel.

Dries moisture, prevents skin breakdown, and preventsperineal infection. Monitors for skin breakdown.

Modification may decrease incidence of diarrhea.

Promotes relaxation and decreases stimulation of bowel.

Helps identify foods that stimulate bowel and exacerbatediarrhea.

Increases the client’s knowledge of causes, treatment, andcomplications of diarrhea. Promotes self-care.

Child Health

The treatment of diarrhea is obviously dictated by its severity, and the resultant effect on hydration and electrolyte bal-ance, and is managed according to individual factors such as age, possible etiology, and status of the infant/child. As arule, the younger the child, the more severe the effects of diarrhea. Children experiencing malnutrition, or with a com-promised immune status, are typically affected more than others. Additional factors include overcrowding and potentialcontamination of milk.




••••••


Child Health


Weigh diapers for urine and stools; assess specific gravityafter each voiding.

Monitor for signs and symptoms of dehydration:• Depressed anterior fontanel in infants• Poor skin turgor• Decreased urinary output

Monitor signs and symptoms associated withbowel movement, including cramping, flatus, andcrying.

Provide prompt and gentle cleansing after each diaperchange. For older children, offer warm soaks after eachdiarrheal episode.

• Collaborate with the physician regarding:• Frequent stooling (more than three times per shift)• Excessive vomiting • Possible dietary alterations for specific formula

or diet• Monitoring electrolytes and renal function• Maintenance of intravenous (IV) fluids• Antidiarrheal medications free of opioids.

A strict assessment of intake and output serves as a basisfor monitoring the efficacy of the treatment and mayprovide a database for treatment protocol. Hydrationis monitored via specific gravity as an indication ofthe renal ability to adjust to fluid and electrolyteimbalance.

Dehydration is extremely dangerous for the infant andrequires close monitoring to offset the effects of dehy-dration.

Associated signs and symptoms serve as supportive datato follow the altered bowel function, with an emphasison related pain or discomfort.

Skin breakdown occurs in a short period of time becauseof frequent bowel movements and the resultant skinirritation.

These nursing measures constitute routine measures tomonitor diarrhea and its related problems. Promptreporting and intervention decrease the likelihood ofmore serious complications.

Oral rehydration therapy is favored when acute diarrheaoccurs.

Women’s Health

l N O T E : Some women experience diarrhea 1 or 2 days before labor begins. It is notcertain why this occurs, but it is thought to be due to the irritation of the bowel by thecontracting uterus and the decrease in hormonal levels (estrogen and progesterone) inlate pregnancy. For diarrhea that is a precursor to labor, the following action applies.


Offer oral electrolyte solutions such as:• Gatorade®

• Classic Coca-Cola®

• Jell-O®

• Pedialyte®

Provides nutrition, electrolytes, and minerals that supporta successful labor process. Recent research has shownthat women can safely eat light foods or drink fluidsduring labor to maintain energy and fluid balance,without harm. There was no increased vomiting in thelater stages of labor than has been historically reported.However, because of other multiple variables present inthe acute care setting, the authors could not provideconvincing evidence to change practice.26


Diarrhea 251

••••••

Mental Health


Monitor lithium levels when these clients present withdiarrhea.

Discuss with the client the role stress and anxiety play inthis problem.

Develop with the client a stress reduction plan and prac-tice specific interventions three times a day at [listtimes here].

Refer to Chapter 8 for specific nursing actions related tothe diagnosis of anxiety.

Diarrhea can be a normal side effect with the initiation ofLi therapy. It is more common in toxicity. Fluid andelectrolyte imbalance caused by diarrhea fluid loss canincrease the risk of Li toxicity.23

Diarrhea can be related to autonomic nervous systemresponse to emotions.27

Promotes the client’s adaptive response to stress, and pro-motes the client’s sense of control.

Gerontic Health


Monitor medication intake to assess for potential sideeffect of diarrhea.

Collaborate with the physician regarding possible alter-ations in medications to decrease the problem of diar-rhea.

Frequently offer electrolyte-rich fluids of choice to pre-vent dehydration.

Carefully monitor the client for early symptoms of dehy-dration.

The older adult may be having diarrhea as a result ofantibiotic therapy, use of drugs with a laxative effect,such as magnesium-based antacids, or as a sign of drugtoxicity secondary to antiarrhythmics, such as digitalis,quinidine, or propranolol.

Provides nutrition, electrolytes, and minerals to offset orprevent dehydration.



Teach the client and family:• How to monitor perianal skin integrity• Techniques of perianal hygiene• Techniques of maintaining fluid and electrolyte balance

(see Adult Health)• Administering antidiarrheal medications

Assist the client and family to set criteria to help themdetermine when a physician or other intervention isrequired (e.g., child having more than three stools in1 day).


• Avoid drinking local water when traveling in areaswhere water supply may be contaminated (e.g., foreigncountries or streams and lakes when camping).

Similar to Adult Health. For Home Health, the locus ofcontrol is now the client and family, not the nurse.

Provides the client and family background knowledge toseek appropriate assistance as need arises.

Behaviors to prevent recurrence of or continuation of theproblem.



READINESS FOR ENHANCEDURINARY ELIMINATION

DEFINITION13

A pattern of urinary functions that is sufficient for meetingeliminatory needs and that can be strengthened.


1. The patient expresses willingness to enhance urinaryelimination.

2. Urine is straw colored with no odor.3. Specific gravity is within normal limits.4. The amount of output is within normal limits for age

and other factors.

5. The patient positions him- or herself for emptying ofbladder.

6. Fluid intake is adequate for daily needs.

EXPECTED OUTCOME

Will maintain or improve current state of urinary elimina-tion patterns by [date].

TARGET DATES

As this is a positive diagnosis with predominantly teachinginterventions, appropriate target dates can be as long as 7 to10 days with intermittent reassessment weekly.


••••••




• Practice stress management.• Avoid laxative or enema abuse.• Avoid foods that cause symptoms.• Avoid bingeing behavior.

Assess the client/family need for adult diapers, linens.Make referrals for obtaining these supplies as appro-priate.

Educate the client in the importance of handwashing.

Educate the client and caregivers about proper handling,cooking, and storage of food.


To prevent the spread of microorganisms that may causediarrhea.

To prevent the spread of microorganisms that may causediarrhea.


Adult Health


Assist the patient in devising fluid management planincluding:

• Adequate fluid intake• Limiting fluids proximal to bedtime

Assist the patient in identifying and managing medica-tions and substances that potentiate urgency, have adiuretic or urinary retention effect.

Assist the patient in creating an environment conducive tocontinence.

Obtain assistive devices as needed (e.g., bedside com-mode, seat adapters, safety frames).

Assist the patient in devising initial toileting schedule[list here]. Assist in revising plan as patient progresses.

Assures adequate fluid intake for physiological needs anddecreases potential for infection.

Enables patient to incorporate effects of medications intodevised toileting plan.

Removal of obstacles can decrease incontinent episodesby facilitating accessibility.

Facilitates accessibility and safety.


Readiness for Enhanced Urinary Elimination 253

••••••


Assist patient in identifying appropriate bladder trainingprogram:

• Pelvic muscle training program• Biofeedback• Scheduled voiding

Follow up weekly [list dates here]. Monitors progress and allows for appropriate revisionof plan.

Child Health


Assess for all possible contributory factors to consider,especially cultural influences.

Offer a child-oriented approach.

Validate readiness for the toddler:• Physical• Ability to hold urine for 2 hours or more• Gross motor skills of sitting, walking, and squatting• Fine motor skills for self-removal of clothing• Mental• Recognizes cues for need to urinate• Cognitive capacity to role model others in toileting

behaviors• Psychological• Expresses willingness to please parent• Capacity to self-identify wet diaper and desire to be dry

Validate readiness for the caregiver(s):• Recognizes toddler’s cues for readiness.• Verbalizes willingness to invest time for assisting with

the urination pattern.• Verbalizes absences of major family stressors that

would interfere with success of pattern (divorce, move,addition of new sibling).

Acknowledges readiness to approximate 18 months ofage with pattern for girls to exhibit earlier patterns thanboys.

Acknowledge cultural aspects for family.

Consider use of free-standing potty chair and/or transi-tional portable seat attached to toilet.

Practice sessions should be limited to no more than10 minutes with parent in presence of toddler.

Praise the child for cooperative behaviors.Use dolls, books, or other materials for learning that are

appropriate for the toddler or child.Assist the caregiver(s) and child to identify related

assistance necessary to carry out plan, especiallymodified equipment to augment stability of pottychair or toilet.

Provides the most inclusive base for care.

Appropriately validates realistic expectations for thechild.29,30

Validates realistic expectations.

Sensitivity to family values creates respect and pro-vides a likelihood of success in follow-through ofpattern.

Provides a sense of security for child.

Ensures safety and allows for natural elimination ofurine.

Offers reinforcement of learning.Provides nonstressful learning at an appropriate level

with greater likelihood for success.Satisfies individual needs to increase likelihood of safety

and success in dealing with the pattern.30,31




••••••


Women’s Health

Interventions for Adult Health apply to women, along with the following considerations:


A thorough assessment and physical exam to determinethe extent of the problem should be performed. Includein the assessment physical problems, patient’s mobility,and environment.

Engage the patient in bladder training:• Postpone voiding.• Urinate at timed intervals by developing a schedule of

urination.• Biofeedback• Medication

Age-related changes of aging contribute to urinary incon-tinence in older women. Lack of care and assessment,as well as the patient’s inability or reluctance to dis-cuss problems with her health-care provider results inapproximately 40 percent of the admissions to nursinghomes.16

Learning different techniques can result in a 50 percentreduction of incontinence in some women. “Controlrequires intact cognitive, neurologic and physicalparameters as well as motivational and environmentalfactors.”30

Mental Health

Nursing interventions for this diagnosis are the same as those for Adult Health.

Gerontic Health

In addition to the interventions for Adult Health, the following may apply to the aging client:


Maintain fluid intake:

• Encourage fluids to at least 2000 mL per day.

Increase client activity if client is sedentary.

Beginning on day of admission, teach the client the fol-lowing exercises:

• Bent-knee sit-ups• Bent-leg lifts• Contracting posterior perineal muscles as if trying to

stop a bowel movement• Contracting anterior perineal muscles as if trying to

stop voiding• Starting and stopping urine stream

Ensures sufficient fluid intake, but restricts fluid whenactivity decreases. Assists in preventing nocturia.

Dilute urine discourages bacterial growth.

Strengthens muscles and promotes kidney and bladderfunctioning.

Strengthens pelvic floor muscles.

URINARY INCONTINENCE

DEFINITIONS13

Urinary Incontinence The state in which the individualexperiences a disturbance in urine elimination.

Functional Urinary Incontinence Inability of usu-ally continent person to reach toilet in time to avoid unin-tentional loss of urine.

Reflex Urinary Incontinence An involuntary lossof urine at somewhat predictable intervals when a specificbladder volume is reached.

Stress Urinary Incontinence The state in which anindividual experiences a loss of urine of less than 50 mLoccurring with increased abdominal pressure.

Total Urinary Incontinence The state in which anindividual experiences a continuous and unpredictable lossof urine.


Urge Urinary Incontinence The state in which anindividual experiences involuntary passage of urine occur-ring soon after a strong sense of urgency to void.

Risk for Urge Urinary Incontinence Risk for invol-untary loss of urine associated with a sudden, strong sensa-tion or urinary urgency.


A. Urinary Incontinence1. Incontinence2. Urgency3. Nocturia4. Hesitancy5. Frequency6. Dysuria7. Retention

B. Functional Urinary Incontinence1. May only be incontinent in early morning2. Senses need to void3. Amount of time required to reach toilet exceeds

length of time between sensing urge and uncontrolledvoiding

4. Loss of urine before reaching toilet5. Able to empty bladder completely

C. Reflex Urinary Incontinence1. No sensation of urge to void2. Complete emptying with lesion above pontine mic-

turition center3. Incomplete emptying with lesion above sacral mic-

turition center4. No sensation of bladder fullness5. Sensations associated with full bladder such as

sweating, restlessness, and abdominal discomfort6. Unable to cognitively inhibit or initiate voiding7. No sensation of voiding8. Predictable pattern of voiding9. Sensation of urgency without voluntary inhibition of

bladder contractionD. Stress Urinary Incontinence

1. Reported or observed dribbling with increasedabdominal pressure

2. Urinary frequency (more often than every 2 hours)3. Urinary urgency

E. Total Urinary Incontinence1. Constant flow of urine occurring at unpredictable

times without distention, or uninhibited bladder con-tractions or spasms

2. Unsuccessful incontinence refractory treatments3. Nocturia4. Lack of perineal or bladder-filling awareness5. Unawareness of incontinence

F. Urge Urinary Incontinence1. Urinary urgency2. Bladder contracture or spasm3. Frequency (voiding more often than every 2 hours)4. Voiding in large amounts (more than 550 mL)

5. Voiding in small amounts (less than 100 mL)6. Nocturia (more than two times per night)7. Inability to reach toilet in time

G. Risk for Urge Urinary Incontinence1. Effects of medication, caffeine, alcohol2. Detrusor hyperreflexia from cystitis, urethritis, tumor,

renal calculi, and central nervous system disordersabove pontine micturition center

3. Detrusor muscle instability with impaired con-tractibility

4. Involuntary sphincter relaxation5. Ineffective toileting habits6. Small bladder capacity

RELATED FACTORS13

A. Urinary Incontinence1. Urinary tract infection2. Anatomic obstruction3. Multiple causality4. Sensory motor impairment

B. Functional Urinary Incontinence1. Psychological factors2. Impaired vision3. Impaired cognition4. Neuromuscular limitations5. Altered environmental factors6. Weakened supporting pelvic structures

C. Reflex Urinary Incontinence1. Tissue damage from radiation, cystitis, inflammatory

bladder conditions, or radical pelvic surgery2. Neurologic impairment above level of sacral micturi-

tion center or pontine micturition centerD. Stress Urinary Incontinence

1. Weak pelvic muscles and structural supports2. Overdistention between voidings3. Incompetent bladder outlet4. Degenerative changes in pelvic muscles and struc-

tural supports associated with increased age5. High intra-abdominal pressure (e.g., obesity, gravid

uterus)E. Total Urinary Incontinence

1. Neuropathy preventing transmission of reflex indicat-ing bladder fullness

2. Trauma or disease affecting spinal cord nerves3. Anatomic (fistula)4. Independent contraction of detrusor reflex due to sur-

gery5. Neurologic dysfunction causing triggering of micturi-

tion at unpredictable timesF. Urge Urinary Incontinence

1. Alcohol2. Caffeine3. Decreased bladder capacity (e.g., history of pelvic

inflammatory disease, abdominal surgeries, orindwelling urinary catheter)

4. Increased fluids

Urinary Incontinence 255

••••••



••••••

5. Increased urine concentration6. Irritation of bladder stretch receptors causing spasm

(e.g., bladder infection)7. Overdistention of bladder

G. Risk for Urge Urinary IncontinenceThe risk factors also serve as the Related Factors.


1. Spinal cord injury2. Urinary tract infection3. Alzheimer’s disease4. Pregnancy5. Abdominal surgery6. Prostate surgery

EXPECTED OUTCOME

Will remain continent at least 90 percent of the time by [date].

TARGET DATES

Treatment of incontinence requires training time and effort;therefore, a target date 5 days from the date of admissionwould be reasonable to evaluate the client’s progress towardmeeting the expected outcome. In addition, there must be arealistic potential that urinary continence may be regainedby the client. For this reason, it would need to be qualifiedfor use with handicapped or neurologically deficient clientsaccording to the exact level of continence desired.


ConstipationAnything in the body that creates additional pressureon the bladder or bladder sphincter may precipitate

voiding. Constipation can create this additional pres-sure because of the increased amount of fecal mate-rial in the sigmoid colon and rectum. Incontinencemay then be a direct result of constipation or fecalimpaction.

Excess Fluid Volume or Deficient Fluid VolumeBecause urination depends on input of the stimu-lus that the bladder is full and because one of theways the body responds to excess fluid volume isby increasing urinary output, the very fact that thereis excess fluid volume may result in the bladder’sinability to keep up with the kidney’s productionof urine. Thus, incontinence may occur. Conversely,Deficient Fluid Volume can result in incontinenceby eliminating the sensation of a full bladder andby decreasing the person’s awareness of thesensation.

Impaired Physical MobilityAs previously stated, the individual must be able tocontrol the sphincter, walk a few steps, recognize andinterpret that the bladder is full, and be able to indi-cate that he or she wants to go to the bathroom. Evenif the person has some control of the sphincter andhas correctly recognized and interpreted the cues of afull bladder, if he or she is unable to get to the bath-room or get there in time because of mobility prob-lems, incontinence may result. This may happenespecially in a hospital.

Impaired Verbal CommunicationThe ability to verbally communicate the need tourinate is important. If the person is unable to tellsomeone or have someone understand that he orshe wants to go to the bathroom, incontinencemay occur.


Adult Health


Record:• Time and amounts of each voiding• Whether voiding was continent or incontinent• The patient’s activity before and after incontinent

incidenceMonitor:• At least every 2 hours on [odd/even] hour, for

continence.• Weight at least every 3 days• Laboratory values (e.g., electrolytes, white blood cells

[WBC], or urinalyses)• For dependent edema• Intake and output, each shift

Helps determine patient’s voiding pattern and monitorseffectiveness of treatment.

Basic methods to monitor hydration, prevent tissueintegrity problems, prevent infection, and promotecomfort.



••••••


• Perineal skin integrity at least once per shift• For bladder distention at least every 2 hours on

[odd/even] hour

Schedule fluid intake:• Avoid fluids containing caffeine and other fluids that

produce a diuretic effect (e.g., coffee, grapefruit juice,and alcohol).

• Offer 8 ounces of fluid every 2 hours on [odd/even]hour during the day.

• Limit fluids after 6 p.m.

Maintain bowel elimination. Monitor bowel movements,and record at least once each shift.

Beginning on day of admission, teach and have thepatient return-demonstrate perineal skin care.

Respond immediately to the patient’s request for voiding.

Implement scheduled voiding regimens which mayinclude:

• Schedule toileting every 2 hours on [odd/even] hourduring the day.

• Schedule toileting at least 30 minutes before foresee-able incontinence times.

• Awaken the patient once during the night for voiding.• Verbally prompting the patient to void every 2 hours on

[odd/even] hour. Praise the patient for appropriate toi-leting.

Stimulate voiding at scheduled time by:• Assisting the patient to maintain normal anatomic posi-

tion for voiding.• Teach trigger techniques to stimulate voiding (e.g.,

gently tapping over bladder or having the patient listento dripping water).21

• Using Credé’s or Valsalva maneuver• Providing privacy• Providing night light and clear path to bathroom

Implement bladder training, including gradually increas-ing time between voiding [Note schedule here.]

Implement strategies to strengthen pelvic floor muscleexercises, including Kegel exercises, biofeedback tech-niques, or vaginal weight training.

Consult with the physician about the use of occlusivedevices that mechanically block the leakage of urine bysupporting the urethrovesical junction or occluding theurethral meatus.

Assist the patient with stress reduction and relaxationtechniques at least once per shift.

Collaborate with the physician regarding intermittentcatheterization and obtaining postvoid residual volumes.

Collaborate with the rehabilitation nurse clinician toestablish a bladder-retraining program.

Assists in predicting times of voiding. Decreases urge tovoid at unscheduled times.

Fullness in bowel may exert pressure on bladder, causingbladder incontinence.

Prevents skin irritation, infection, and odor.

Immediate response may prevent an incontinent episode.

Voiding at scheduled intervals prevents overdistentionand helps establish a voiding pattern.

A normal anatomical position facilitates voiding.

Extending time between voiding will increase volumeof urine in bladder and will stretch bladder.


Promotes relaxation and self-control of voiding.

Prevents complications related to bladder overdistention.

Allows establishment of a program that is current in con-tent and procedures.



Child Health

Nursing actions for the child with incontinence are the same as for Adult Health, with attention to the developmental,anatomic, and physiologic parameters for age and with attention to organic potentials, including congenital malformations.Special allowance for urinary reflux or recurrent potential urinary tract infections should be made in all ages.

The definition is offered for primary enuresis as bedwetting in children who have never been dry for extended periodof time, and secondary enuresis as the onset of wetting after a period of established urinary continence. Nocturnal enure-sis occurs only at nighttime while diurnal enuresis occurs during both day and night. Nocturnal enuresis is more common.

Although most children with enuresis do not experience coexisting psychopathology, some children also experiencedevelopmental disorders, learning problems, or difficulties in behavior. Self-esteem is influenced according to the parentalresponse and especially is vulnerable in harsh or punitive instances. Severe punishment for unrealistic expectations orinappropriate management of enuresis can serve as a trigger for child abuse.29



••••••


Adult Health


Teach the patient exercises to strengthen pelvic floormuscles. Exercise should consist of 10 repetitions atleast three times per day, three to four times a week.[Record date and times exercises are performed here.]

Teach the patient the importance of maintaining a dailyroutine:

• Voiding upon arising• Awakening self once during the night• Voiding immediately before retiring• Not postponing voiding unnecessarily

Discuss possibilities of client regaining continence.Include discussion about techniques to facilitate social-ization:

• Wearing street clothes with protective pads in under-garments

• Maintaining bladder-retraining program• Responding as soon as possible to voiding urge

Consult with physician regarding pharmacologicaltherapy.

Monitor for side effects of pharmacological therapy:• Dry mouth• Constipation• Blurred vision• Dizziness

Refer to home health care agency for follow-up.

Strengthens pelvic floor muscles to better controlvoiding.31

Helps establish urinary elimination pattern, and preventsoverdistention of bladder.

Helps preserve self-concept and body image. Promotescompliance.

Provides continuity of care and support system for ongo-ing care at home.

Assess for all possible contributing factors, including rul-ing out urinary tract infection, structural disorders,neurologic deficits as with myelomeningocele, andconditions with increased urinary output (diabetes mel-litus or diabetes insipidus).

Offers the fullest consideration of causes to best uncoverall factors.32



••••••


Offer psychiatric intervention as the cues arise for needfor same—may be related to sexual abuse or other psy-chological factors.

Obtain history of wetting behavior in a nonjudgmentalmanner including information of toilet training andusual attempts for dealing with the behavior.

Initiate or instruct caregiver(s) and child (as appropriate)on how to do a baseline record of enuresis.

Provide assistance in chosen therapy:• Conditioning therapy includes a stimulus response con-

ditioning often with a pad and buzzer alarm whenmoisture is sensed-used with a success rate of approxi-mately 60 to 90 percent.

• Retention control training is offered for enhancementof bedwetters whose functional bladder capacity wasreduced.

• The waking schedule training includes awakening thechild during the night at intervals. This method is suc-cessful in reducing, but not eliminating incidents.

Drug therapy is used more and more and may includeanticholinergic agents, vasopressin analog desmo-pressin as a nasal spray, and other individualized com-binations of modified doses for these and tricyclicantidepressants or antispasmodics. In these instances,the caregiver(s) must monitor for side effects and safe-guard medications from potential overdose by othersiblings.

Support child and family within a non-punitive frame-work during time of treatment.

Offers the fullest consideration to provide holism.32

Creates a basis for open consideration of problem.32

Provides baseline data to determine the extent of theproblem and assists in monitoring treatment.32

Fosters support to child and family.32

Safeguards child from potential side effects.

Ensures reduction of risk from overdosage.32

Lessens sense of lost self-esteem and offers positive rein-forcement without conditional acceptance of child.32

Women’s Health

l N O T E : The same nursing interventions pertains to Women’s Health as to AdultHealth. During pregnancy, the woman may occasionally experience uncontrolled void-ing before reaching the toilet. This is usually caused by the overexpansion of the uterusor the pressure and weight of the baby and uterus on the bladder. This usually resolvesafter the delivery of the baby. Many women experience uncontrollable leakage of urinedue to injury during pregnancy and childbirth. However, certain medications, such asdiuretics, muscle relaxants, sedatives, and antidepressants, can contribute to urinaryincontinence.


Assist the client in identifying lifestyle adjustments thatmay be needed to accommodate changing bladdercapacity caused by anatomic changes of pregnancy.

• Teach the client to recognize symptoms of urinary tractinfection (urgency, burning, or dysuria).

• Teach the client how to take temperature (make surethe client knows how to read thermometer).

• Instruct the client to seek immediate medical care ifsymptoms of urinary tract infection appear.

Bladder capacity is reduced because of enlarging uterus,displacement of abdominal contents by enlargeduterus, and pressure on bladder by enlarged uterus.




••••••


Women’s Health


Teach women Kegel exercises and pelvic floor muscula-ture retraining.

Encourage good hygiene and cleansing of the perineum,wiping from front to back to prevent urinary tractinfections.

Discuss the physiological changes women experience asthey age that affect the bladder and can lead to inconti-nence.

• Ability of bladder to expand decreases.• Involuntary bladder contraction increase.• Bladder outlet loses strength and resistance of pelvic

floor muscles resulting in being unable to close.• Urethra shortens and weakens.• Ability to postpone voiding decreases.• Postvoiding residual volume increases.

Provide a nonjudgmental, relaxed atmosphere that willencourage the woman to ask questions without embar-rassment.

Strengthening of pelvic floor muscles helps reduce theurge to void and prevents leakage of urine.

Loss of estrogen after menopause contributes to weaken-ing of pelvic muscle fibers. Bladder training, educa-tion, biofeedback along with medications includingoral or vaginal estrogen can help alleviate some of thesymptoms of incontinence.30

Mental Health

l N O T E : If the alteration is related to psychosocial issues and has no physiologic com-ponent, initiate the nursing actions that follow. (Refer to Adult Health for physiologically-produced problems.)


Monitor times, places, persons present, and emotional cli-mate around inappropriate voiding episodes.

Remind the client to void before a high-risk situation orremove secondary gain process from situation.

Provide the client with supplies necessary to facilitateappropriate voiding behavior (e.g., urinal for the clientin locked seclusion area).

Inform the client of acceptable times and places for void-ing and of consequences for inappropriate voiding.[Note consequences here.]

Have the client assist with cleaning up any voiding thathas occurred in an inappropriate place.

Provide as little interaction with the client as possibleduring cleanup.

Provide the client with positive reinforcement for voidingin appropriate place and time. [List specific reinforcersfor the client here.]

Spend [number] minutes with the client every hour in anactivity the client has identified as enjoyable; do notprovide this time, or discontinue time, if the client

Identifies target behaviors, and establishes a baselinemeasurement of behavior with possible reinforcersfor inappropriate behavior.18

Removes positive reinforcement for inappropriatebehavior.18

Appropriate behavior cannot be implemented withoutthe appropriate equipment.18

Negative reinforcement eliminates or decreasesbehavior.18

Provides a negative consequence for inappropriatebehavior.18

Lack of social response acts as negative reinforcement.18

Positive reinforcement encourages appropriate behavior.18

Interaction with the nurse can provide positive reinforce-ment. Withdrawing attention for inappropriate behaviorprovides negative reinforcement.18



••••••


inappropriately voids during the specified time. [Listidentified activities here.]

If the client voids inappropriately [number] during a shift,he or she will spend [number] minutes (no more than30) in time-out. Each inappropriate voiding in time-outadds 5 minutes to this time.

As behavior improves, add rewards for accumulatedtimes of appropriate voiding (e.g., award a 2-hour passfor 1 day of appropriate voiding). [Record theserewards here.]

Negative consequences decrease or eliminate undesirablebehavior.18

Intermittent reinforcement can render a response moreresistant to extinction once it has been established.18

l N O T E : Refer to Chapters 8 and 11 for interventions related to the specific alterationsthat would promote this coping pattern.

Gerontic Health

Incontinence is not a normal part of aging. When older adults experience incontinence efforts should be made to bothdetermine the cause of the incontinence and return the client to a continent state.



Review medication record for drugs such as sedatives,hypnotics, or diuretics that may contribute to urinaryincontinence.

Assist the client/caregiver to establish a schedule forvoiding.

Modify the environment to facilitate continence:• Call bells within reach• Bedside commode, urinal, bedpan as appropriate in

reach• Clear, unobstructed path to toileting facilities• Well lit toileting facilities

Modify the client’s garments as appropriate to facilitatecontinence:

• Elastic waist pants rather than zippers or buttons• Pants rather than one-piece garments such as coveralls• Knee high hose rather than panty hose

Sedatives and hypnotics may result in a delayed responseto the urge to void. Diuretic therapy, depending ondosage and time of administration, may result in aninability to reach the bathroom in a timely manner.

Promotes bladder tone, helps prevent accidents fromdecreased sense of urge to void.

Prevents urgency incontinence due to environmentalbarriers.

Prevents urgency incontinence due to difficulty removinggarments.

Home Health

l N O T E : If this nursing diagnosis is made, it is imperative that a physician referralalso be made. If referred to home care under a physician’s care, it is important to main-tain and evaluate response to prescribed treatments.



• Using proper perineal hygiene• Taking showers instead of tub baths• Drinking fluids to cause voiding every 2 to 3 hours to

flush out bacteria• Scheduling fluid intake

Basic measures to prevent recurrence.




••••••


Home Health


• Voiding after intercourse• Avoiding bubble baths, perfumed soaps, toilet paper,

or feminine hygiene sprays• Wearing cotton underwear• Using proper handwashing techniques• Following a daily routine of voiding (see Adult Health

actions)• Establishing a bladder-retraining program• Doing exercises to strengthen pelvic floor muscles

Providing an environment conducive to continence:• Clear path to the bathroom• A light in the bathroom• Bedside commode as needed• Clothes that are easily removed• Wearing street clothes and protective underwear• Using an air purifier• Performing activities as tolerated• Providing unobstructed access to bathroom• Avoiding fluids that produce diuretic effect (e.g.,

caffeine, alcohol, or teas)

Teach the client and family to dilute and acidify the urineby:

• Increasing fluids• Introducing cranberry juice, poultry, etc., to increase

acid ash

Teach the client and family to monitor and maintain skinintegrity:

• Keep skin clean and dry.• Keep bed linens and clothing clean and dry.• Use proper perineal hygiene.

Assist the client and family to set criteria to help themdetermine when a physician or other intervention isrequired (e.g., hematuria, fever, or skin breakdown).

Monitor and teach the importance of appropriate medica-tions and treatments ordered by physician.

Refer to appropriate assistive resources as indicated.

Educate the client about the importance of urinating on aregular basis, prior to urge.

Assist the client in obtaining necessary personal hygienesupplies as needed (e.g., pads, diapers, linens).

Educate the client about prescribed medications and theirpossible side effects.

Dilute urine and acidic urine discourage bacterial growth.

Prevents or minimizes problems secondary to inconti-nence.

Assists in preventing or minimizing further physiologicdamage.

Additional resources may be needed based on the under-lying problem.

Empties the bladder before stretching or distentionoccurs.

Provides a sense of security.

Promotes sense of accountability and improves compli-ance.


Urinary Retention 263

••••••

URINARY RETENTION

DEFINITION13

The state in which the individual experiences incompleteemptying of the bladder.


1. Bladder distention2. Small, frequent voiding or absence of urine output3. Sensation of bladder fullness4. Dribbling5. Residual urine6. Dysuria7. Overflow incontinence

RELATED FACTORS13

1. High urethral pressure caused by weak detrusor2. Inhibition of reflex arc3. Strong sphincter4. Blockage


1. Benign prostatic hyperplasia2. Hysterectomy

3. Urinary tract infection4. Cancer

EXPECTED OUTCOME

Will void under voluntary control and empty bladder at leastevery 4 hours by [date].

TARGET DATES

Urinary retention poses many dangers to the client. Anacceptable target date to evaluate for lessening of retentionwould be within 24 to 48 hours after admission.


Urinary IncontinenceOverflow incontinence frequently occurs in clientswhose primary problem is really retention. The bladderis overdistended in retention, and some urine ispassed involuntarily because of the pressure of theretained urine on the bladder sphincter.

Self-Care Deficit, ToiletingIn neurogenic bladder conditions, the bladder is chron-ically overdistended, resulting in urinary retention.


Adult Health


Monitor bladder for distention at least every 2 hours on[odd/even] hour.

Measure and record intake and output each shift.

Maintain fluid intake:• Encourage fluids to at least 2000 mL per day.• Limit fluids after 6 p.m.

Monitor:• Bowel elimination at least once per shift• Urinalysis, electrolytes, and weight at least every 3 days

Increase client activity:• Ambulate at least twice per shift while awake at [times].• Collaborate with the physical therapist, soon after the

patient’s admission, regarding an exercise program.

Collaborate with the rehabilitation nurse clinician to initi-ate a bladder-retraining program.

Stimulate micturition reflex every 4 hours while awake at[times]:

• Assist the client to assume an anatomically correctposition for voiding.

• Remind the client to be consciously aware of need-to-void sensations.

Monitors pattern and determines effectiveness of treat-ment; helps prevent complications.

Monitors fluid balance.

Ensures sufficient fluid intake, but restricts fluid whenactivity decreases. Assists in preventing nocturia.

Constipation may block bladder opening and lead toretention. Empty bowel facilitates free passage ofurine.

Strengthens muscles and promotes kidney and bladderfunctioning.

Allows establishment of a program that is current in con-tent and procedures.

Helps relax sphincter and strengthens the voiding reflex.




••••••


Adult Health


• Teach the client to assist bladder contraction:• Credé’s maneuver• Valsalva maneuver• Abdominal muscle contraction• Pelvic floor muscle exercises, alternating contraction

and relaxation of perineal muscles while sitting in achair and with feet placed apart on floor.

Collaborate with physician regarding:• Intermittent catheterization• Pharmacological agents• Medications (e.g., urinary antiseptics or analgesics)

Refer to home health agency as appropriate at least2 days prior to discharge for continued monitoring.

Strengthens the pelvic floor and abdominal muscles.

Relieves bladder distention, assists in scheduling voiding,and prevents infection.

Provides continuity of care and a support system forongoing home care.

Child Health

l N O T E : For infants and children less than 20 pounds, it would be necessary to calcu-late exact intake and output and fluid requisites according to the etiologic factors pres-ent. Attention must be paid to the child’s physiologic developmental level regardingurinary control.


Provide opportunities for the child and parents to verbal-ize concerns or views about body image disturbancesrelated to urinary control and retention. Spend at least30 minutes per shift in privacy with the child and par-ents to permit this verbalization.

Monitor parental (client as applicable) knowledge of pre-ventive health care for the client:

• Teaching and observation of urinary catheterization• Maintenance of catheters and supplies• How to obtain supplies• How to obtain a sterile culture specimen• Appropriate restraint of the infant• Potential regarding urinary control

Provide opportunities for parental participation in thecare of the infant or child:

• Feedings• Bathing• Monitoring intake and output. Caution for removal of

too much urine* and for reporting of excessive patternof urinary production as with diabetes insipidus.

• Planning for care to include individual preferenceswhen possible

• Assisting with procedures when appropriate• Provision of safety needs• Cautious handwashing to prevent infection33

• Appropriate emotional support

Assists in reducing anxiety, and attaches value to theclient’s and parents’ feelings. Promotes the develop-ment of a therapeutic relationship.29

Parental knowledge will assist in the reduction of anxietyand will provide a greater likelihood for compliancewith the desired plan of care.29

Appropriate parental involvement provides opportunitiesfor trial care and allows the parents to practice care ina safe, supportive environment before the time of moretotal self-care.29

Helps to monitor for other factors to be addressed andprevents hypovolemia, secondary to excessive removalof urine according to age/size of child.29



••••••


• Appropriate diversional activity and relaxation• Need for pain medication

Collaborate with other health-care professionals asneeded.

Assist the family to identify support groups representedin the community for future needs.

*Varies by size and age–get norms

Identification of support for the family will best assistthem to comply with the desired plan of care whilereducing anxiety and promoting self-care.29,33

Women’s Health

Actions and rationales are the same for Adult Health except in the following situation.


Collaborate with the physician regarding intermittentcatheterization.

It is not easy to catheterize a woman postpartum, nor isit desirable to introduce an added risk of infection, soevery effort and support should be directed towardhelping the woman to void on her own. If, however,she is unable to void or to empty her bladder, anindwelling catheter may be placed for 24 to 48 hoursto rest the bladder and allow it to heal, edema to sub-side, and bladder and urethral tone to return.22

Mental Health

l N O T E : Clients receiving antipsychotic and antidepressant drugs are at increasedrisk for this diagnosis.23 Refer to Adult Health for general actions related to this dia-gnosis.


Place clients receiving antipsychotic or antidepressantmedication on a daily assessment for this diagnosis.Elderly clients should be evaluated more frequently iftheir physical status indicates.

Monitor the bladder for distention at least every 4 hours at[times] if verbal reports are unreliable or if they indi-cate a voiding frequency greater than every 4 hours.

Increase the client’s activity by:• Walking with the client [number] minimum of three

times per day at [list times here]• Collaborating with the physical therapist regarding an

exercise program. Note the plan developed with thephysical therapist here.

• Placing the client in a room distant from the day area,nursing stations, and other activity if condition does notcontraindicate this

• Providing physical activities that the client indicates areof interest. [List those here with the time for each.]

Teach deep muscle relaxation, and spend 30 minutestwice a day at [list times here] practicing this with the

Early intervention and treatment ensures better out-come.23

Activity maintains muscle strength necessary for mainte-nance of normal voiding patterns. (See Adult Healthfor specific exercises to strengthen pelvic floor mus-cles.)

Anxiety can increase muscle tension and therefore con-tribute to urinary retention.18

Anxiety can increase muscle tension and therefore con-tribute to urinary retention.18




••••••

Gerontic Health

l N O T E : Obstructive voiding symptoms secondary to prostate disease include hesi-tancy, decreased force of stream, terminal dribbling, postvoid fullness, and double void-ing. Benign prostatic hypertrophy (BPH) is the most common cause of prostaticenlargement requiring intervention. Seventy-five percent of men older than 80 years ofage experience BPH and the resulting urinary symptoms.


Collect a thorough and comprehensive history of theclient’s symptoms.

Review the medication record for use of anticholinergic,antidepressant, and antipsychotic medications.

Assist the client and physician in determining the causeof retention.

The use of anticholinergic, antidepressant, and antipsy-chotic medication can result in urinary retention as aside effect.

Home Health

l N O T E : If this nursing diagnosis is made, it is imperative that physician referral bemade. Vigorous intervention is required to prevent damage or systemic infection. Ifreferred to home care under a physician’s care, it is important to maintain and evaluatethe patient’s response to prescribed treatments.


Assist the client and family in lifestyle changes that maybe required:

• Monitor bladder for distention.• Record intake and output.• Stimulate micturition reflex. (See Adult Health.)• Institute bladder-retraining program.• Perform exercises to strengthen pelvic floor muscles.• Use proper position for voiding.• Maintain fluid intake.• Maintain physical activity as tolerated.• Use straight catheterization.

Assist the client and family to set criteria to help themdetermine when a physician or other intervention isrequired (e.g., specified intake and output limit, pain,or bladder distention).

Assess the client/caregiver understanding of prescribedmedications. Provide teaching as needed.


Similar to Adult Health. Locus of control now is with thefamily and client.

Knowledge will assist the client and family to seek timelyinterventions.

Facilitates self-care.

Additional support may be required to help the client andfamily maintain care at home.


Mental Health


client. Associate relaxation with breathing so that theclient can eventually relax with deep breathing whileattempting to void.

Collaborate with the physician regarding catheterizationand medication adjustments.

Catheterization increases the risk for infection, so everyeffort and support should be directed toward helpingthe client to void on his or her own.


R E F E R E N C E S1. Taylor C, Lillis C, and LeMone, P: Fundamentals of Nursing: The Art

and Science of Nursing Care, ed 5. Lippincott, Williams & Wilkins,New York, 2005.

2. McCance, K, and Huether, S: Pathophysiology: The Biologic Basisfor Disease in Adults and Children, ed 5. Mosby, St. Louis, 2005.

3. Author: Dehydration and fluid maintenance, American MedicalDirectors Association (AMDA), 2001.

4. Folden, SL, et al: Practice Guidelines for the Management ofConstipation in Adults. Association of Rehabilitation Nurses,Glenview, IL, 2002.

5. Locke, GR, Pemberton, JH, and Phillips, SF: AmericanGastroenterological Association medical position statement:Guidelines on constipation. Gastroenterology 119:6, 1761, 2000.

6. Hay-Smith, EJC, et al: Pelvic floor muscle training for urinary incon-tinence in women. Cochrane Incontinence Group, Cochrane Databaseof Systematic Reviews I, 2006.

7. Mallett, VT: Female urinary incontinence: What the epidemiologicdata tell us. Int J Fertil Womens Med 50:1, 12, 2005.

8. Karon, S: A team approach to bladder retraining: A pilot study. UrolNurs 25:4, 269, 2005.

9. Freiberg, K: Annual Editions: Human Development. McGraw-Hill/Dushkin, Boston, 2005.

10. Ebersole, P, Hess, P, and Lugen, A: Toward Healthy Aging: HumanNeeds and Nursing Response, ed 6. Mosby, St. Louis, 2004.

11. Best Practice 3:1, 1999. (http://www.bestpractices.org/bpbriefs/)12. Graf, C: Functional decline in hospitalized older adults. Am J Nurs

106:1, 58, 2006.13. Author: Nursing Diagnosis: Definitions and Classification, 2005–

2006. North American Nursing Diagnosis Association, NANDAInternational, 2005.

14. Schmelzer, M: Effectiveness of wheat bran in preventing constipationof hospitalized orthopaedic surgery patients. Orthop Nurs 9:55, 1990.

15. Fogel, CI, and Wood, NF: Health Care of Women: A NursingPerspective, CV Mosby, St. Louis, 1981.

16. Patrick, T: Female physical development. In Breslin, ET, and Lucas,VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.WB Saunders, Philadelphia, 2003.

17. Erickson, H, Tomlin, E, and Wsain, M: Modeling and Role-Modeling:A Theory and Paradigm for Nursing. Prentice-Hall, Englewood Cliffs,NJ, 1983.

18. Kneisl, C, Wilson, H, and Trigoboff, E: Contemporary Psychiatric-Mental Health Nursing, Pearson Education, Upper Saddle River, NJ,2004.

19. Lange, N, and Tigges, BB: Nurse Practitioner 30:44, 2005.20. Kozier, B: Fundamentals of Nursing: Concepts, Process, and

Practice, ed 7. Prentice Hall Health, Upper Saddle River, NJ,2004.

21. Smeltzer, SC, et al: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, ed 10. Lippincott, Williams & Wilkins,Philadelphia, 2003.

22. Lowdermilk, DL, and Perry, SE: Maternity & Women’s Care, ed8. CV Mosby, St. Louis, 2004.

23. Maxmen, J, and Ward, N: Psychotropic Drugs Fast Facts. WWNorton, New York, 2002.

24. Management of Constipation in Older Adults. Best Practice 3(1):4,1999.

25. Heather, C, et al: Effect of bulk forming cathartic on diarrhea in tubefed patients. Heart Lung 20:409, 1991.

26. Tranmer, JE, Hodnett, ED, Hannah, ME, and Stevens, BJ: The effectof unrestricted oral carbohydrate intake on labor process. JOGNN34:3, 319, 2005.

27. Black, JM, and Matassarin-Jacobs, E: Medical-Surgical Nursing:Clinical Management for Continuity of Care, ed 5. WB Saunders,Philadelphia, 1997.

28. Stadtler, AC, Gorski, PA, and Brazleton, TB: Toilet training methods,clinical interventions and recommendations. Pediatrics 103:6, 1359,1999.

29. MJ Hockenberry, Wong’s Clinical Manual of Pediatric Nursing. CVMosby, St. Louis, 2003.

30. Sellers, JB: Health care for older women. In Breslin ET, and Lucas,VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.WB Saunders, Philadelphia, 2003.

31. Nygarrd, IE, and Heit, M: Stress urinary incontinence. Am CollObstet Gynecol 104:3, 2004.

32. Fritz, G, et al: Practice parameter for assessment and treatmentof children and adolescents with enuresis. American Academyof Child and Adolescent Psychiatry (AACAP), Washington, DC,2002.

33. Author: Evaluation and treatment of urinary tract infections inchildren. American Academy of Family Physicians. Wright StateUniversity School of Medicine, Dayton OH, 2005. (http://www.aafp.org//afp/980401ap?ahmed2.html)


••••••


5ACTIVITY–EXERCISEPATTERN

1. ACTIVITY INTOLERANCE, RISK FORAND ACTUAL 283

2. AIRWAY CLEARANCE, INEFFECTIVE292

3. AUTONOMIC DYSREFLEXIA, RISK FORAND ACTUAL 299

4. BED MOBILITY, IMPAIRED 304

5. BREATHING PATTERN, INEFFECTIVE307

6. CARDIAC OUTPUT, DECREASED 313

7. DISUSE SYNDROME, RISK FOR 321

8. DIVERSIONAL ACTIVITY, DEFICIENT327

9. DYSFUNCTIONAL VENTILATORYWEANING RESPONSE (DVWR) 331

10. FALLS, RISK FOR 336

11. FATIGUE 340

12. GAS EXCHANGE, IMPAIRED 346

13. GROWTH AND DEVELOPMENT,DELAYED; DISPROPORTIONATEGROWTH, RISK FOR; DELAYEDDEVELOPMENT, RISK FOR 353

14. HOME MAINTENANCE, IMPAIRED 360

15. INFANT BEHAVIOR, DISORGANIZED,RISK FOR AND ACTUAL, ANDREADINESS FOR ENHANCEDORGANIZED 365

16. PERIPHERAL NEUROVASCULARDYSFUNCTION, RISK FOR 370

17. PHYSICAL MOBILITY, IMPAIRED 373

18. SEDENTARY LIFESTYLE 381

19. SELF-CARE DEFICIT (FEEDING,BATHING-HYGIENE, DRESSING-GROOMING, TOILETING) 386

20. SPONTANEOUS VENTILATION,IMPAIRED 393

21. TISSUE PERFUSION, INEFFECTIVE(SPECIFY TYPE: RENAL, CEREBRAL,CARDIOPULMONARY, GASTRO-INTESTINAL, PERIPHERAL) 396

22. TRANSFER ABILITY, IMPAIRED 406

23. WALKING, IMPAIRED 408

24. WANDERING 411

25. WHEELCHAIR MOBILITY, IMPAIRED415


270 Activity—Exercise Pattern

••••••

PATTERN DESCRIPTION

This pattern focuses on the activities of daily living (ADLs)and the amount of energy the individual has available tosupport these activities. The ADLs include all aspectsof maintaining self-care and incorporate leisure time aswell. Because the individual’s energy level and mobilityfor ADLs are affected by the proper functioning of theneuromuscular, cardiovascular, and respiratory systems,nursing diagnoses related to dysfunctions in these systemsare included.

As with the other patterns, a problem in the activ-ity–exercise pattern may be the primary reason for thepatient entering the health-care system or may arise second-ary to problems in another functional pattern. Any admis-sion to a hospital may promote the development of problemsin this area because of the therapeutics required for the med-ical diagnosis (e.g., bed rest) or because of agency rules andregulations (e.g., limited visiting hours).

PATTERN ASSESSMENT

1. Does the patient’s heart rate or blood pressure increaseabnormally in response to activity?a. Yes (Activity Intolerance)b. No

2. Does the patient have dyspnea after activity?a. Yes (Activity Intolerance)b. No

3. Does the patient have a medical diagnosis related to thecardiovascular or respiratory system?a. Yes (Risk for Activity Intolerance)b. No

4. Does the patient have a history of Activity Intolerance?a. Yes (Risk for Activity Intolerance, Sedentary

Lifestyle)b. No

5. Does the patient complain of fatigue, weakness, or lackof energy?a. Yes (Activity Intolerance or Fatigue)b. No

6. Is the patient unable to maintain his or her usual rou-tines?a. Yes (Fatigue or Self-Care Deficit)b. No

7. Does the patient report difficulty in concentrating?a. Yes (Fatigue)b. No

8. Review self-care chart. Does the patient have any self-care deficits?a. Yes (Self-Care Deficit [specify which area])b. No

9. Can the patient engage in a usual hobby while inhospital?a. Yesb. No (Deficient Diversional Activity)

10. Does the family need help with home maintenanceafter the patient goes home?a. Yes (Impaired Home Maintenance)b. No

11. Does the patient have health insurance?a. Yesb. No (Impaired Home Maintenance)

12. Is the patient within height and weight norm for age?a. Yesb. No (Delayed Growth and Development)

13. Can the patient perform developmental skills appropri-ate for age level?a. Yesb. No (Delayed Growth and Development)

14. Are there any abnormal movements?a. Yes (Disorganized Infant Behavior)b. No

15. If the patient is an infant, does he or she respondappropriately to stimuli?a. Yesb. No (Disorganized Infant Behavior)

16. Does the patient’s cardiogram indicate arrhythmias?a. Yes (Decreased Cardiac Output)b. No

17. Is the patient’s jugular vein distended?a. Yes (Decreased Cardiac Output)b. No

18. Are the patient’s peripheral pulses within normallimits?a. Yesb. No (Decreased Cardiac Output, Ineffective Tissue

Perfusion, or Risk for Peripheral NeurovascularDysfunction)

19. Are the patient’s extremities cold?a. Yes (Ineffective Tissue Perfusion or Risk for

Peripheral Neurovascular Dysfunction)b. No

20. Does the patient have claudication?a. Yes (Ineffective Tissue Perfusion or Risk for


21. Does the patient have full range of motion?a. Yesb. No (Impaired Physical Mobility or Impaired

Walking)22. Does the patient have problems moving self

in bed?a. Yes (Impaired Bed Mobility)b. No

23. Does the patient have problems ambulating?a. Yes (Impaired Physical Mobility or Impaired

Walking)b. No

24. Is the patient paralyzed?a. Yes (Risk for Disuse Syndrome)b. No


25. Is the patient immobilized by casts or traction?a. Yes (Risk for Disuse Syndrome or Risk for


26. Does the patient have a spinal cord injury at T7 orabove?a. Yes (Risk for Autonomic Dysreflexia)b. No

27. Does the patient have a spinal cord injury at T7 orabove and paroxysmal hypertension?a. Yes (Autonomic Dysreflexia)b. No

28. Does the patient have a spinal cord injury at T7 orabove and bradycardia or tachycardia?a. Yes (Autonomic Dysreflexia)b. No

29. Review the mental status examination. Is the patientexhibiting confusion or drowsiness?a. Yes (Impaired Gas Exchange)b. No

30. Review blood gas levels. Does the patient demonstratehypercapnia?a. Yes (Impaired Gas Exchange or Impaired

Spontaneous Ventilation)b. No

31. Were rales (crackles) or rhonchi (wheezes) present onchest auscultation?a. Yes (Ineffective Airway Clearance)b. No

32. Is respiratory rate increased above the normal range?a. Yes (Ineffective Airway Clearance or Ineffective

Breathing Pattern)b. No

33. Is the patient on a ventilator? If yes, does the patienthave restlessness or an increase from baseline of bloodpressure, pulse, or respiration when weaning isattempted?a. Yes (Dysfunctional Ventilatory Weaning Response)b. No

34. Does the patient have dyspnea and shortness of breath?a. Yes (Ineffective Breathing Pattern, Impaired

Spontaneous Ventilation, or Activity Intolerance)b. No

35. Is the patient exhibiting pursed-lip breathing?a. Yes (Ineffective Breathing Pattern)b. No

36. Does the patient have a history of falling?a. Yes (Risk for Falls)b. No

37. Does the patient have diminished mental status?a. Yes (Risk for Falls)b. No

38. Does the patient have difficulty in manipulating his orher wheelchair?a. Yes (Impaired Wheelchair Mobility)b. No

39. Can the patient independently transfer him- or herselffrom site to site?a. Yesb. No (Impaired Transfer Ability)


Several nursing diagnoses are included in this pattern that, atfirst glance, seem to have little relationship with each other.However, closer investigation demonstrates that there isone concept common to all of the diagnoses: immobility.Immobility, or the impulses that control and coordinatemobility, can contribute to the development of any of thesediagnoses, or any of these diagnoses can ultimately lead tothe development of immobility.

Mobility and immobility are end points on a contin-uum with many degrees of impaired mobility or partialmobility between the two points.1 Immobility is usually dis-tinguished from impaired mobility by the permanence of thelimitation. A person who is quadriplegic has immobility,because it is permanent; a person with a long cast on the leftleg has impaired mobility, because it is temporary.2

Mobility is defined as the ability to move freely andis one of the major means by which we define and expressourselves. The central nervous system integrates the stim-uli from sensory receptor nerves of the peripheral nerv-ous system and projection tracts of the central nervoussystem to respond to the internal or external environmentof the individual. This integration allows for movementand expressions. A problem with mobility can be a measureof the degree of the illness or health problem of an indi-vidual.3

Patients with self-care deficits are most often thosewho are experiencing some type of mobility problem.2

Mobility problems require greater energy expenditure,which leads to activity intolerance, deficient diversionalactivity, and impaired home maintenance simply because ofthe lack of energy or nervous system response to engage inthese activities.

Problems with mobility and nervous system responsealso lead to other physical problems. When a person hasimpaired mobility or immobility, bed rest is quite often pre-scribed or is voluntarily sought in an effort to conserveenergy. Several authors3–5 describe the physical problemsthat can occur secondary to prolonged bed rest:

1. Respiratory: Decreased chest and lung expansioncauses slower and more shallow respiration. Pooling ofsecretions occurs secondary to decreased respiratoryeffort and the effects of gravity. The cough reflex isdecreased as a result of decreased respiratory effort,gravity, and decreased muscle strength. Acid–base bal-ance is shifted, causing a retention of carbon dioxide.Respiratory acidosis causes changes in mentation:vasodilatation of cerebrovascular blood vessels and


••••••


increased cerebral blood flow, headache, mentalcloudiness, disorientation, dizziness, generalized weak-ness, convulsions, and unconsciousness. In addition,because of the buildup of carbon dioxide in the lungs,adequate oxygen cannot be inspired, leading to tissuehypoxia.

2. Cardiovascular: Circulatory stasis is caused by vasodi-latation and impaired venous return. Muscular inactivityleads to vein dilation in dependent parts. Gravity effectsalso occur. Decreased respiratory effort and gravity leadto decreased thoracic and abdominal pressures that usu-ally assist in promoting blood return to the heart. Quiteoften patients have increased use of the Valsalva maneu-ver, which leads to increases in preload and afterload ofcardiac output and, ultimately, a decreased cardiac out-put. Continued limitation of activity leads to decreasedcardiac rate, slower circulatory volume, and arterialpressure as a result of redistribution of body fluids.Venous stasis contributes to the potential for deepvenous thrombosis and pulmonary embolus. After pro-longed bed rest, the normal neurovascular mechanism ofthe cardiovascular system that prevents large shifts inblood volume does not function adequately. When theindividual who has experienced extended bed restattempts to assume an upright position, gravity pulls anexcessive amount of blood volume to the feet and legs,depriving the brain of adequate oxygen. As a result, theindividual experiences orthostatic hypotension.4

3. Musculoskeletal: Inactivity causes decreased bonestress and decreased muscle tension. Osteoblastic andosteoclastic activities become imbalanced, leading tocalcium and phosphorus loss. Decreased muscle useleads to decreased muscle mass and strength as a resultof infrequent muscle contractions and protein loss.

4. Metabolic: Basal metabolic rate and oxygen consump-tion decrease, leading to decreased efficiency in usingnutrients to build new tissues. Normally, body tissuesbreak down nitrogen, but apparently muscle mass losswith accompanying protein loss leads to nitrogen lossand a negative nitrogen balance. Changes in tissuemetabolism lead to increased potassium and calciumexcretion. Decreased energy use and decreased basalmetabolic rate (BMR) lead to appetite loss, which leadsto a decrease in the nutrient intake necessary to offsetlosses.

5. Skin: The negative nitrogen balance previously dis-cussed, coupled with continuous pressure on bonyprominences, leads to a greatly increased potential forskin breakdown.

Immobility is not the sole causative factor of the nurs-ing diagnoses in this pattern. Many of the diagnoses can berelated to specific medical diagnoses, such as congestiveheart failure, or may occur as a result of diagnoses in thispattern, for example, Delayed Growth and Development.

However, the concept of immobility does serve to point outthe interrelatedness of the diagnoses.

Because fatigue plays a major role in determining thequality and amount of musculoskeletal activity undertaken,consideration of the factors that influence fatigue is anessential part of nursing assessment for the activity–exercisepattern. Fatigue might be considered in two general cate-gories: experiential and muscular. The degree to which theindividual participates in activity is significant in determin-ing the fatigue experienced. Activities that the individualenjoys are less likely to produce fatigue than are those notenjoyed. Preferences should be considered within the frame-work of capacity and needs. Obviously, other factors thatmust be considered include the physical and medical condi-tion of the person and his or her emotional state, level ofgrowth and development, and state of health in general.Oxygenation needs and extrinsic factors also need to beaddressed. If there is overstimulation, such as with noise,extremes of temperature, or interruption of routines, agreater amount of fatigue or disorganized behavior can beexpected. Sensory understimulation with resultant boredomcan also contribute to fatigue.

Fatigue can develop as a result of too much wastematerial accumulating and too little nourishment going tothe muscles. Muscle fatigue usually is attributed to the accu-mulation of too much lactic acid in the muscles. Certainmetabolic conditions, such as congestive heart failure, placea person at greater risk for fatigue.


Diet, musculoskeletal factors, and respiratory and cardio-vascular mechanisms influence activity. Developmental con-siderations for diet are addressed in Chapter 3. Thedevelopmental considerations discussed here specificallyrelate to musculoskeletal, respiratory, and cardiovascularfactors.

INFANT

Many things, including genetic, biologic, and cultural fac-tors, influence physical and motor abilities. Nutrition, matu-ration of the central nervous system, skeletal formation, andoverall physical health status, as well as amount of stimula-tion, environmental conditions, and consistent loving carealso play a part in physical and motor abilities.6 Girls usu-ally develop more rapidly than do boys, although boys havea higher activity level.6

All muscular tissue is formed at birth, but growthoccurs as the infant uses the various muscle groups. This usestimulates increased strength and function.

The infant engages in various types of play activity atvarious times in infancy because of developing skills andchanging needs. The infant needs the stimulation of parents


••••••


in this play activity to develop fully. However, parentsshould be aware of the dangers of overstimulation. Fatigue,inattention, and injury to the infant may result.6

Interruptions in the normal developmental sequenceof play activities due to illness or hospitalization, for exam-ple, can have a detrimental effect on the future developmentof the infant or child. An understanding of the normalsequence of play development is important so that therapeu-tic interventions can be designed to approximate the devel-opmental needs of the individual.

The structural description of play developmentfocuses on the Piagetian concepts of the increasing cognitivecomplexity of play activities. Elementary sensorimotor-based games emerge first, with the gradual development ofadvanced social games in adulthood.7

Play activities assist in the child’s development of psy-chomotor skills and cognitive development. Socializationskills are learned and practiced via the interaction with oth-ers during play. As the child begins to learn more about hisor her body during play, he or she will incorporate morecomplicated gross and fine motor skills. Play is extremelyvaluable in the development of language and other commu-nication skills. Play helps the individual establish controlover self and the environment and provides a sense ofaccomplishment. Through play activities, the infant learns totrust the environment. Play also affords the child the oppor-tunity to express emotions that would be unacceptable inother normal social situations.

Practice games begin during the sensorimotor level ofcognitive development at 1 to 4 months of age, and continuewith increasing complexity throughout childhood. Thesegames include skills that are performed for the pleasure offunctioning, that is, for the pleasure of practice.

Symbolic games appear later during the sensorimotorperiod than do practice games—at about age 12 to 18months. Make-believe is now added to the practice game.Other objects represent elements of absent objects or per-sons. As previously stated, activity is influenced by respira-tory and cardiovascular mechanisms.

The respiratory mechanisms, or air-conducting pas-sages (nose, pharynx, larynx, trachea, bronchi, bronchioles,and alveoli) and lungs, of the infant are small, delicate, andimmature. The air that enters the nose is cool, dry, and unfil-tered. The nose is unable to filter the air, and the mucousmembranes of the upper respiratory tract are unable to pro-duce enough mucus to humidify or warm the inhaled air.Therefore, the infant is more susceptible to respiratory tractinfections.7

In addition, the infant is a nose breather. When upperrespiratory tract infections do occur, the infant is unable toclear the airways appropriately and may get into some diffi-culty until he or she learns to breathe through his or hermouth (at about 3 to 4 months of age). The cough of theinfant is not very effective, and the infant quickly becomesfatigued with the effort.7

In the lungs, the alveoli are functioning, but not allalveoli may be expanded. Therefore, there is a large amountof dead space in the lungs. The infant has to work harder toexchange enough oxygen and carbon dioxide to meet bodydemands. The elevated respiratory rate of the infant (30 to60 per minute) reflects this increased work. In addition, arte-rial blood gases of the infant may show an acid–base imbal-ance. The rate and rhythm of respiration in the infant issomewhat irregular, and it is not unusual for the infant to useaccessory muscles of respiration. Retractions with respira-tion are common.

The alveoli of the infant increase in number and com-plexity very rapidly. By 1 year of age, the alveoli and the lin-ing of the air passages have matured considerably.

Respiratory tract obstructions are common in this agegroup because of the short trachea and the almost straight-line position of the right main stem bronchus. In addition,the epiglottis does not effectively close over the tracheaduring swallowing. Thus, foreign objects are aspirated intothe lungs.

In terms of cardiovascular development, the foramenovale closes during the first 24 hours, and the ductus arte-riosus closes after several days. The neonate can survivemild oxygen deprivation longer than an adult can. TheApgar scoring system is used to measure the physical statusof the newborn and includes heart rate, color, and respira-tion. There is no day–night rhythm to the neonate’s heartrate, but from the sixth week on, the rate is lower at nightthan during the day. Axillary temperature readings and age-sized blood pressure cuffs should be used to assess vitalsigns. The pulse is 120 to 150 beats per minute; respirationranges from 35 to 50 per minute; and blood pressure rangesfrom 40 to 90 mm Hg systolic and 6 to 20 mm Hg diastolic.Vital signs become more stable over the first year. Listeningfor murmurs should be done over the base of the heart ratherthan at the apex. Breath sounds are bronchovesicular. Theneonate has limited ability to respond to environmental tem-perature changes and loses heat rapidly. This leads to anincreased basal metabolic rate (BMR) and an increasedworkload on the heart. Until patients reach age 7, the apex ispalpated at the fourth interspace just to the left of the mid-clavicular line.


By this age, the child is walking, running, climbing, andjumping. The toddler is very active and curious. He or shegets into everything. This helps the toddler organize his orher world and develop spatial and sensory perception.6 It isduring this period that the child begins to see him- or herselfas a person separate from his or her parents and the envi-ronment. This increasing level of autonomy also presents achallenge for the caregivers. The child alternates betweenthe security of the parents and the exciting exploration of theenvironment.


••••••


The toddler is fairly clumsy, but gross and fine motorcoordination is improving. Neuromuscular maturation andrepetition of movements help the child further developskills.6 Muscles grow faster than bones during these years.Safety is a major concern for children of this age. The tod-dler, especially, wants to do many things for him- or herself,thus testing control of self and the environment.

Bathing and HygieneBy the age of 3, the child can wash and dry his or her handswith some wetting of clothes and can brush his or her teeth,but requires assistance to perform the task adequately. Bythe fourth birthday, the child may bathe him- or herself withassistance. The child will be able to bathe him or herselfwithout assistance by the age of 5. Both parents and nursesmust keep in mind the safety issues involved in bathing; thechild requires supervision in selection of water temperatureand in the prevention of drowning.

Dressing and GroomingAt age 18 to 20 months, the child has the fine motor skillsrequired to unzip a large zipper. By 24 to 48 months, thechild can unbutton large buttons. The child can put on acoat with assistance by age 2; the child can undress him- orherself in most situations and can put on his or her owncoat without assistance by age 3. At 31/2 years the childcan unbutton small buttons, and by 4 years can button smallbuttons. Dressing without assistance and a beginning abilityto lace shoes are accomplishments of the 5-year-old. Thedevelopment of fine motor skills is required for most ofthe tasks of dressing. It is important that the child’s cloth-ing have fasteners that are appropriate for the motor skilldevelopment. The child will require assistance with decid-ing the appropriateness of clothing selected; seasonal vari-ations in weather and culturally accepted norms regardingdressing and grooming are learned by the child with assis-tance.

FeedingThe child can drink from a cup without much spilling by 18months. The child will have frequent spills while trying toget the contents of a spoon into his or her mouth at this age.By 2 years of age, the child can drink from a cup; use of aspoon has improved at this age, but the child will still spillliquids (soup) from a spoon when eating. The child can eatfrom a spoon without spilling by 31/2 years. Accomplisheduse of a fork occurs at 5 years.

ToiletingBy age 3, the child can go to the toilet without assistance;the child can pull pants up and down for toileting withoutassistance at this stage as well. The development of foodpreferences, preferred eating schedules and environment,and toileting behavior are imparted to the child by learning.Toileting, food, and the eating experience may also includepleasures, control issues, and learning tasks in addition tothe development of the motor skills required to accomplish

the task. Delays or regressions in the tasks of self-feedingmay reflect issues other than a self-care deficit, for example,discipline, family coping, and role-relationships.

PhysiologyDuring the preschool years, the child seems to have anunlimited supply of energy. However, he or she does notknow when to stop and may continue activities past the pointof exhaustion. Parents should provide a variety of activitiesfor these age groups, as the attention span is short.

The lung size and volume of the toddler have nowincreased, and thus the oxygen capacity of the toddler hasincreased. The toddler is still susceptible to respiratory tractinfections but not to the same extent as the infant. The rateand rhythm of respiration have decreased, and respirationsaverage 25 to 35 per minute. Accessory muscles of respira-tion are used infrequently now, and respiration is primarilydiaphragmatic.

The respiratory structures (trachea and bronchi) arepositioned farther down in the chest now, and the epiglottisis effective in closing off the trachea during swallowing.Thus, aspiration and airway obstruction are reduced in thisage group.

The respiratory rate of the preschooler is about 30 perminute. The preschooler is still susceptible to upper respira-tory tract infections. The lymphatic tissues of the tonsils andadenoids are involved in these respiratory tract infections.Tonsillectomies and adenoidectomies are no longer per-formed “routinely.” These tissues serve to protect the respi-ratory tract, and valid reasons must be presented to warranttheir removal.

The temperature of the toddler ranges around 99�F �1� (orally); pulse ranges around 105 beats per minute � 35;respirations range from 20 to 35 per minute; and blood pres-sure ranges from 80 to 100 mm Hg systolic and 60 to 64 mmHg diastolic. The size of the vascular bed increases in thetoddler, thus reducing resistance to flow. The capillary bedhas increased ability to respond to environmental tempera-ture changes. Lung volume increases. Breath sounds aremore intense and more bronchial, and expiration is morepronounced. The toddler’s chest should be examined withthe child in an erect position, then recumbent, and thenturned to the left side. Arrhythmias and extrasystoles are notuncommon but should be recorded.

The temperature of the preschooler is 98.6� F � 1�(orally); pulse ranges from 80 to 100 beats per minute; res-piration is 30 per minute � 5; and blood pressure is 90/60mm Hg � 15. There is continued increase of the vascularbed, lung volume, and so on, in keeping with physicalgrowth.

SCHOOL-AGE CHILDWhereas the muscles were growing faster than the bonesduring the toddler and preschool years, the skeletal systemis growing rapidly during these years—faster than the mus-


••••••


cles are growing. Children may experience “growing pains”because of the growth of the long bones. There is a gradualincrease in muscle mass and strength, and the body takes ona leaner appearance. The child loses his or her “baby fat,”muscle tone increases, and loose movements disappear.Adequate exercise is needed to maintain strength, flexibility,and balance and to encourage muscular development.7

Males have a greater number of muscle cells than females.Posture becomes more upright and straighter but is not nec-essarily influenced by exercise. Posture is a function of thestrength of the back muscles and the general state of healthof the child. Poor posture may be reflective of fatigue as wellas skeletal defects,7 with fatigue being exhibited by suchbehaviors as quarrelsomeness, crying, or lack of interest ineating. Skeletal defects such as scoliosis begin to appearduring this period.

Neuromuscular coordination is sufficient to permitthe school-age child to learn most skills6; however, careshould be taken to prevent muscle injuries. Hands andfingers manipulate things well. Although children age 7have a high energy level, they also have an increased atten-tion span and cognitive skills. Therefore, they tend to engagein quiet games as well as active ones. Seven-year-oldstend to be more directed in their range of activities. Gameswith rules develop as the child engages in more socialcontacts. These games characteristically emerge duringthe operational phase of cognitive development in the schoolage child. These rule games may also be practice or sym-bolic in nature, but now the child attaches social signif-icance and order to the play by imposing the structureof rules.

Eight-year-olds have grace and balance. Nine-year-olds move with less restlessness, their strength andendurance increase, and their hand–eye coordination isgood.6 Competition among peers is important to test outtheir strength, agility, and coordination. Although 10- to 12-year-old children are better able to control and direct theirhigh energy level, they do have energetic, active, restlessmovements with tension release through finger drumming,foot tapping, or leg swinging.

The respiratory rate of the school-age child slows to 18to 22 per minute. The respiratory tissues reach adult matu-rity, lung volume increases, and the lung capacity is propor-tionate to body size. The school-age child is still susceptibleto respiratory tract infections. The frontal sinuses are fairlywell developed by this age, and all the mucous membranesare very vulnerable to congestion and inflammation. Thetemperature, pulse, and respiration of the school-age childare gradually approaching adult norms, with temperatureranging from 98 to 98.6�F, pulse (resting) 60 to 70 beats perminute, and respiration from 18 to 20 per minute. Systolicblood pressure ranges from 94 to 112 mm Hg, and diastolicfrom 56 to 60 mm Hg. The heart grows more slowly duringthis period and is smaller in relation to the rest of the body.Because the heart must continue to supply the metabolic

needs, the child should be advised against sustained physicalactivity and be watched for tiring. After age 7, the apex of theheart lies at the interspace of the fifth rib at the midclavicu-lar line. Circulatory functions reach adult capacity. The childwill still have some vasomotor instability with rapid vasodi-lation. A third heart sound and sinus arrhythmias are fairlycommon but, again, should be recorded.

ADOLESCENT

Growth in skeletal size, muscle mass, adipose tissue, andskin is significant in adolescence. The skeletal system growsfaster than the muscles; thus, stress fractures may result. Thelarge muscles grow faster than the smaller muscles, with theoccasional result of poor posture and decreased coordina-tion. Boys are clumsier than girls. Muscle growth continuesin boys during late adolescence because of androgen pro-duction.6

Physical activities provide a way for adolescents toenjoy the stimulation of conflict in a socially acceptableway. Some form of physical activity should be encouragedto promote physical development, prevent overweight, for-mulate a realistic body image, and promote peer acceptance.

The respiratory rate of the adolescent is 16 to 20 perminute. Parts of the body grow at various rates, but the res-piratory system does not grow proportionately. Therefore,the adolescent may have inadequate oxygenation andbecome more fatigued. The lung capacity correlates with theadolescent’s structural form. Boys have a larger lung capac-ity than girls because of greater shoulder width and chestsize. Boys have greater respiratory volume, greater vitalcapacity, and a slower respiratory rate. The boy’s lungcapacity matures later than the girl’s. Girls’ lungs mature atage 17 or 18.

The heart continues to grow during adolescence butmore slowly than the rest of the body, contributing to thecommon problems of inadequate oxygenation and fatigue.The heart continues to enlarge until age 17 or 18. Systolicpulse pressure increases, and the temperature is the same asin an adult. The pulse ranges from 50 to 68 beats per minute;respiration ranges from 18 to 20 per minute; and blood pre-ssure is 100 to 120/50 to 70 mm Hg. Adolescent girlshave slightly higher pulse rates and basal body temperatureand lower systolic pressures than boys. Hypertension inci-dence increases. Essential hypertension incidence is approx-imately equal between races for this age group.

Athletes have slower pulse rates than peers. Heartsounds are heard readily at the fifth left intercostal space.Functional murmurs should be outgrown by this time. Chestpain may arise from musculoskeletal changes, but cardio-vascular pain should always be investigated. Cardiovascularproblems are the fifth leading cause of death in adolescents.

More rest and sleep are needed now than earlier. Theteenager is expending large amounts of energy and func-tioning with an inadequate oxygen supply; both these fac-


••••••


tors contribute to fatigue and lead to the need for additionalrest. Parents may need to set limits. Rest does not necessar-ily mean sleep and can also include quiet activities.6

Because of the very rapid growth during this period,the adolescent may not have sufficient energy left for stren-uous activities. He or she tires easily and may frequentlycomplain of needing to sit down. Gradually the adolescent isable to increase both speed and stamina during exercise. Anincrease in muscular and skeletal strength, as well as theincreased ability of the lungs and heart to provide adequateoxygen to the tissue, facilitates maintenance of hemody-namics and rate of recovery after exercise. The body reachesits peak of physiologic resilience during late adolescenceand young adulthood. Regular physical training and an indi-vidualized conditioning program can increase both strengthand tolerance to strenuous activity.

Faulty nutrition is another major cause of fatigue inthe adolescent. Poor eating habits established during theschool-age years, combined with the typical quick-service,quick-energy food consumption patterns of adolescents, fre-quently lead to anemia, which in itself can lead to activityintolerance.7

The adolescent may be given responsibility for assist-ing with the maintenance of the family home, or may beresponsible for his or her own home if living independentfrom the family of origin. The role exploration characteris-tic of adolescence may lead to temporary changes inhygiene practices.

Recreational activities in adolescence often take theform of organized sports and other competitive activities.Social relationships are developed and enhanced, specificmotor and cognitive skills related to a specific sport arerefined, and a sense of mastery can be developed. Groupactivities and peer approval and acceptance are important.The adolescent responds to peer activities and experimentswith different roles and lifestyles. The nurse must distin-guish self-care practices that are acceptable to the peergroup from those that indicate a self-care deficit.

YOUNG ADULT

Growth of the skeletal system is essentially complete by age25. Muscular efficiency is at its peak between 20 and 30.Energy level and control of energy are high. Thereafter,muscular strength declines with the rate of muscle aging,depending on the specific muscle group, the activity of theperson, and the adequacy of his or her diet.

Regular exercise is helpful in controlling weight andmaintaining a state of high-level wellness. Muscle tone,strength, and circulation are enhanced by exercise. Problemsarise especially when sedentary lifestyles decrease theamount of exercise available with daily activities. Caloricintake and exercise should be balanced.

Adequate sleep is important for good physical andmental health. Lack of sleep results in progressive sluggish-ness of both physical and cognitive functions. The majoractivities of individuals in this age group are work and

leisure-time pursuits. The young adult should learn to bal-ance his or her work with leisure-time activities. Gettingstarted in a career can be very stressful and can lead toburnout if an appropriate balance is not found. Physical fit-ness reflects ability to work for a sustained period with vigorand pleasure, without undue fatigue, and with energy leftover for enjoying hobbies and recreational activities and formeeting emergencies.6

Basic to fitness are regular physical exercise, pro-per nutrition, adequate rest and relaxation, conscientioushealth practices, and good medical and dental care. Regularphysical fitness is a natural tranquilizer releasing the body’sown endorphins, which reduce anxiety and musculartension.

The respiratory system of the young adult has com-pletely matured. Oxygen demand is based on exercise andactivity now but gradually decreases between age 20 and 40.The body’s ability to use oxygen efficiently is dependenton the cardiovascular system and the needs of the skeletalmuscles.

The respiratory and cardiovascular systems changegradually with age, but the rate of change is highly depend-ent on the individual’s diet and exercise pattern. Generally,contraction of the myocardium decreases. Maximum car-diac output is reached between the age of 20 and 30. Thearteries become less elastic. The maximum breathing capac-ity decreases between ages 20 and 40. Cardiac and respira-tory function can be improved with regular exercise.Hypertension (blood pressure 140/90 mm Hg or higher) andmitral valve prolapse syndrome are the most common car-diovascular medical diagnoses of the young adult.

ADULT

Basal metabolism rate gradually decreases. Although thereis a general and gradual decline in quickness and levelof activity, people who were most active among their agegroup during adolescence and young adulthood tend to bethe most active during middle and old age. In women, thereis frequently a menopausal rise in energy and activity.8

Judicious exercise balanced with rest and sleep modify andretard the aging process. Exercise stimulates circulation toall parts of the body, thereby improving body functions.Exercise can also be an outlet for emotional tension. If theperson is beginning exercises after being sedentary, certainprecautions should be taken, such as increasing exercisegradually to a moderate level, exercising consistently, andavoiding overexertion. Research indicates that cardiovascu-lar risk factors can be reduced in women by low-intensitywalking.9

The adult is beginning to have a decrease in bone massand a loss of skeletal height. Muscle strength and mass aredirectly related to active muscle use. The adult needs tomaintain the patterns of activity and exercise of young adult-hood and not become sedentary. Otherwise, muscles losemass structure and strength more rapidly.


••••••


Temperature for the adult ranges from 97 to 99.6�F;pulse ranges from 50 to 100 beats per minute; respirationranges from 16 to 20 per minute; and blood pressure is120/80 mm Hg � 15. Cardiac output gradually decreases,and the decreasing elasticity of the blood vessels causesmore susceptibility to hypertension and cardiovascular dis-eases. After menopause women become as prone to coro-nary disease as men, so estrogen appears to be a protectiveagent. The BMR generally decreases. Essential and second-ary hypertension and angina occur more frequently in thisage group.

The lung tissue becomes thicker and less elastic withage. The lungs cannot expand as they once did, and breath-ing capacity is reduced. The respiratory rate may increase tocompensate for the reduced breathing capacity.

The normal adult should be able to perform activ-ities of daily living without assistance. The need for closerelationships and the intimacy of adulthood can be initi-ated by leisure activities with identified partners or a smallgroup of close friends (e.g., hiking, tennis, golf, or attend-ing concerts or theaters, etc.). The middle-age adult isoften interested in the personal satisfaction of diversionalactivities.

The adult will most likely be responsible for homemaintenance as well as outside employment. Role strain orovertaxation of the adult is possible. Illness or injury to theadults in the household will significantly affect the ability ofthe family unit to maintain the home.

OLDER ADULT

Older adults face a gradual decline in function through theyears. Age-related changes in the cardiovascular, respira-tory, and musculoskeletal systems vary from person to per-son. Studies attempting to describe age-related systemchanges have faced problems in determining what changesmay be age-related versus disease-induced.11

Changes in the older musculoskeletal system typicallyinclude decreases in bone volume and strength, decreases inskeletal muscle quality and mass, and reductions in musclecontractility.11 After the age of 40 to 50, an incrementalprocess of bone absorption without successful new bone for-mation leads to gradual bone loss.12 This loss is greater inwomen, but occurs in both men and women. Tendon and lig-ament strength decrease with aging, and collagen stiffnessand cross-linking occur. The tendon and ligament changescan result in joint range-of-motion losses of 20 to 25 per-cent.11 Changes in older adults vestibular and nervous sys-tems present a challenge to older adults attempting tomaintain balance, prevent falls, and have a smooth gait.13

Vestibular changes can impede spatial orientation. Thevestibular and nervous system changes in conjunction witha slowed reaction time, increased postural sway, decreasedstride, decreased toe-floor clearance, decreased arm swing,and knee and hip rotation all may impact the mobility levelof older adults.14

Age-related changes to the respiratory system mayinclude a decrease in lung elasticity, chest wall stiffness,diminished cough reflex, increased physiologic dead spacesecondary to air trapping, and nonuniform alveolar ventila-tion.15 Alveolar enlargement and thinning of alveolar wallsmean less alveolar surface is available for gas exchange.16

The older adult may experience decreases in PaO2 andincreases in PaCO2 because of age-related changes in the res-piratory system.

Cardiovascular diseases remain the primary cause ofdeath in the older population.17 With aging, the cardiovascu-lar system undergoes changes in structure and function. Leftventricular, aortic, and mitral valve thickening have animpact on cardiac contractility and systolic blood flow.Increased arterial thickness and arterial stiffening may leadto a decrease in the effectiveness of baroreceptors.Diminished baroreceptor response has an effect on thebody’s ability to control blood pressure with posturalchanges. Pacemaker cells in the sinoatrial node decreasewith aging. Calcification may occur along the conductionsystem of the heart. Myocardial irritability leads to thepotential for increased cardiac arrhythmias.16 The ability ofthe cardiovascular system to respond to increased demandsbecomes reduced, and the older adult experiences a decreasein physiologic reserves.16 These changes can have seriousconsequences when the older adult experiences physicalor psychological stress. It becomes increasingly difficultfor the older adult to have rapid and efficient blood pressureand heart rate changes. Vital sign ranges for older adultsare similar to those for middle-age adults. There may be aslight increase in respiratory rate,13 and blood pressureincreases, especially systolic changes, are often present.Healthy older men, from age 50 onward, may experiencea 5 to 8 mm Hg increase in systolic blood pressure perdecade. Healthy older women, from age 40 onward, mayhave similar systolic changes.18 Diastolic changes are usu-ally minimal.

With the potential age-related changes just described,some older adults may experience changes in function.Many of the changes combined can lead to problems withenergy available to cells, organs, and systems to accomplishdesired activities. Health promotion efforts should focus onactivity and exercise and their impact on the older adult’ssense of well-being. Research in the 1990s has shown thebenefits to older adults when weight training and exerciseare a part of their lifestyle.19 Older clients may need prompt-ing and reminders to pace their activities to compensate foraging changes. The increase in leisure time associated withretirement and a lessening of occupational and child-rearingresponsibilities create the opportunity for exploring otheractivity options.

The older adult has the developmental challenge offinding meaning in the course of the life they have livedand feeling comfort with the results of their actions andchoices.20 Strategies to support this task may take on theform of life review with the older client, promoting remi-


••••••



••••••



Activity–Exercise Activity, IntoleranceRisk for & Actual

Airway Clearance,Ineffective

Autonomic Dysreflexia,Risk for & Actual

Bed Mobility, Impaired

Risk ForEnergy ManagementExercise Promotion:

Strength Training

ActualActivity TherapyEnergy ManagementExercise Promotion:

Strength TrainingSelf-Care Assistance:

IADLs

Airway ManagementAsthma ManagementCough ManagementRespiratory Monitoring

Airway ManagementDysreflexia ManagementVital Signs Monitoring

Bedrest CareBody Mechanics

Promotion

Asthma ControlCardiac Pump EffectivenessCirculation StatusCopingEnergy ConservationHealth Beliefs: Perceived ControlImmobility Consequences:

Physiological, Psycho-cognitiveKnowledge: Diet, Disease Process,

Prescribed ActivityMood EquilibriumNutritional Status: Body Mass, EnergyPain: Disruptive Effects, Pain LevelRespiratory Status: Gas Exchange,

VentilationRisk ControlRisk DetectionSymptom ControlSymptom Severity

Knowledge:Aspiration ControlRespiratory Status: Airway Patency,

Gas Exchange, Ventilation

Bowel EliminationCaregiver Home ReadinessComfort LevelInfection StatusKnowledge: Disease Process, Labor

& Delivery, MedicationRisk ControlRisk DetectionThermal RegulationTissue Integrity: Skin & Mucous

MembranesTreatment Behavior: Illness or InjuryUrinary EliminationVital Signs Status

Body Positioning: Self-InitiatedCognitive AbilityJoint Movement: ActiveMobility LevelMuscle FunctionNeurological Status

niscing, and other opportunities for the older adult toacknowledge and experience self-worth.21

Because of the diversity of our older population, indi-vidualized assessment is a high priority. The age-related

changes cited in this section are not universal and inevitablefor all older adults. Health-care providers need to be wary ofstereotyping clients based on age. There are many independ-ent older adults in our society, and the number is increasing.



••••••



Breathing PatternIneffective

Cardiac OutputDecreased

Disuse Syndrome, Riskfor

Diversional Activity,Deficient

DysfunctionalVentilatory WeaningResponse (DVWR)

Falls, Risk for

Fatigue

Gas ExchangeImpaired

Airway ManagementAsthma ManagementRespiratory Monitoring

Cardiac CareCardiac Care: AcuteCirculatory Care: Arterial

Insufficiency,Mechanical AssistDevices, VenousInsufficiency

HemodynamicRegulation

Shock Management

Energy Management

Recreation TherapySelf-responsibility

Facilitation

Mechanical VentilationMechanical Ventilatory

Weaning

Body MechanicsPromotion

Fall PreventionPositioning

Energy Management

Airway ManagementOxygen TherapyRespiratory Monitoring

Respiratory Status: Airway Patency,Ventilation

Vital Signs Status

Cardiac Pump EffectivenessCirculation StatusTissue Perfusion: Abdominal Organs,

PeripheralVital Signs Status

EnduranceEnergy ConservationImmobility Consequence:

Physiological, Psycho-cognitiveJoint Movement: Active, PassiveMobility LevelMuscle FunctionNeurological Status: ConsciousnessPain LevelRisk ControlRisk Detection

Leisure ParticipationPlay ParticipationSocial Involvement

Respiratory Status: Gas Exchange,Ventilation

Vital Signs Status

Activity ToleranceEnduranceEnergy ConservationNutritional Status: EnergyPsychomotor Energy

Electrolyte & Acid–Base BalanceRespiratory Status: Gas Exchange,

VentilationTissue Perfusion: PulmonaryVital Signs Status



••••••



Growth andDevelopment,Delayed

Growth, Risk forDisproportionate

Home Maintenance,Impaired

Infant Behavior,Disorganized, Actual;Risk for; Readinessfor EnhancedOrganized

Developmental CareDevelopmental

Enhancement:Adolescent, Child

Nutrition TherapyNutritional Monitoring

Nutritional MonitoringTeaching: Infant

Nutrition, ToddlerNutrition

Weight Management

Home MaintenanceAssistance

ActualEnvironmental

ManagementPositioning

Risk forEnvironmental

ManagementNewborn MonitoringPositioningSurveillance

Child development: 1, 2, 4, 6, 12months and 2, 3, 4 years;Preschool; Middle Childhood;Adolescence

GrowthPhysical AgingPhysical Maturation: Female; Male

AppetiteBody ImageChild Development: 1, 2, 4, 6, 12

months and 2, 3, 4 years:Preschool; Middle Childhood;Adolescence

GrowthKnowledge: Infant Care;

Preconception Maternal Health;Pregnancy

Parenting PerformancePhysical Maturation: Male; FemalePrenatal Health BehaviorRisk ControlRisk DetectionWeight: Body Mass

Family FunctioningFamily Physical EnvironmentParenting PerformanceParenting: Psychosocial SafetyRole PerformanceSafe Home EnvironmentSelf-Care: Instrumental Activities

of Daily Living (IADLs)

ActualChild Development: 1 Month; 2

MonthsNeurological StatusPreterm Infant OrganizationSleepThermoregulation: Newborn

Risk forChild Development: 1, 2, 4, 6, 12

MonthsCoordinated MovementKnowledge: Infant Care; ParentingNeurological StatusPreterm Infant OrganizationRisk ControlRisk DetectionSleepThermoregulation: Newborn



••••••



PeripheralNeurovascularDysfunction, Risk for

Physical Mobility,Impaired

Sedentary Lifestyle

Self Care Deficit:Feeding, Bathing-Hygiene,Dressing/Grooming,Toileting

Feeding

Bathing/Hygiene

Readiness forEnhanced OrganizedDevelopmental CarePain Management

Exercise Therapy: JointMobility

Peripheral SensationManagement

Exercise Therapy:Ambulation, JointMobility

Positioning


FeedingSelf-care Assistance:

Feeding

BathingSelf-care Assistance:

Bathing/Hygiene

Readiness for EnhancedOrganizedChild Development: 1 Month;

2 MonthsNeurological StatusSleepThermoregulation: Newborn

Blood CoagulationBody Positioning: Self-InitiatedBone HealingCirculation StatusCoordinated MovementJoint Movement: Ankle; Elbow; Hip;

KneeMobilityNeurological StatusNeurological Status: Cranial

Sensory/Motor FunctionNeurological Status: Spinal

Sensory/Motor FunctionRisk ControlRisk DetectionTissue Perfusion: Peripheral

AmbulationAmbulation: WheelchairBalanceBody Mechanics PerformanceBody Positioning: Self-InitiatedCoordinated MovementMobilityTransfer performance


FeedingNutritional StatusNutritional Status: Food and Fluid

IntakeSelf-Care: ADLs; EatingSwallowing Status

BathingOstomy Self-CareSelf-Care: ADL; Bathing; Hygiene;

Oral Hygiene



••••••



Dressing/Grooming

Toileting

Ventilation,SpontaneousImpaired

Tissue Perfusion,Ineffective(Specify Type)

Renal

Cerebral

Cardiopulmonary

Gastrointestinal

Peripheral

DressingHair CareSelf-care Assistance:

Dressing/Grooming

ToiletingEnvironmental ManagementSelf-care Assistance:

Toileting

Artificial Airway ManagementMechanical VentilationRespiratory MonitoringResuscitation: NeonateVentilation Assistance

RenalFluid/Electrolyte

ManagementFluid ManagementHemodialysis TherapyHemofiltration TherapyPeritoneal Dialysis Therapy

CerebralCerebral Perfusion

PromotionIntracranial Pressure (ICP)

MonitoringNeurologic MonitoringPeripheral Sensation

Management

CardiopulmonaryCardiac Care: AcuteCirculatory Care: Arterial

Insufficiency, VenousInsufficiency

Respiratory MonitoringShock Management: Cardiac

GastrointestinalFluid/Electrolyte

ManagementGastrointestinal IntubationNutrition Management

PeripheralCirculatory Care: Arterial

Insufficiency, VenousInsufficiency

Neurologic Monitoring

DressingSelf-Care: ADL; Hygiene; Dressing

ToiletingKnowledge: Ostomy CareOstomy Self-CareSelf-Care: ADL; Hygiene; Toileting

Allergic Response: SystemicMechanical Ventilation Response:

AdultRespiratory Status: Gas Exchange;

VentilationVital Signs

RenalCirculation StatusElectrolyte & Acid–Base BalanceFluid BalanceFluid Overload SeverityKidney FunctionTissue Perfusion: Abdominal

Organs

CerebralCognitive AbilityNeurological StatusNeurological Status:

Consciousness, Central MotorControl

Swallowing StatusTissue Perfusion: Cerebral

CardiopulmonaryCardiac Pump EffectivenessCirculation StatusRespiratory Status: Gas ExchangeTissue Perfusion: Cardiac;

PulmonaryVital Signs

GastrointestinalElectrolyte & Acid–Base BalanceFluid BalanceHydrationTissue Perfusion: Abdominal

Organs

PeripheralCirculation StatusFluid Overload SeverityTissue Integrity: Skin & Mucous

MembranesTissue Perfusion: Peripheral


Activity Intolerance, Risk For and Actual 283

••••••


Transfer Ability, Impaired

Walking, Impaired

Wandering

Wheelchair, Mobility:Impaired

Exercise Promotion:Strength Training

Self-care Assistance:Transfer

Exercise Therapy:Ambulation

Area RestrictionDementia

ManagementEnvironmental

Management: Safety

Positioning:Wheelchair

BalanceBody Mechanics PerformanceBody Positioning: Self-InitiatedCoordinated MovementMobilityTransfer Performance

AmbulationBalanceCoordinated MovementEnduranceMobility

Fall Prevention BehaviorSafe Home Environment

Adaptation to Physical DisabilityAmbulation: WheelchairBalanceCoordinated MovementMobilityTransfer Performance


ACTIVITY INTOLERANCE,RISK FOR AND ACTUAL

DEFINITIONS22

Risk for Activity Intolerance A state in which an indi-vidual is at risk of experiencing insufficient physiologic orpsychological energy to endure or complete required ordesired daily activities.

Activity Intolerance A state in which an individualhas insufficient physiologic or psychological energy toendure or complete required or desired daily activities.


A. Risk for Activity Intolerance (Risk Factors)1. Inexperience with the activity2. Presence of circulatory or respiratory problems3. History of previous intolerance4. Deconditioned status

B. Activity Intolerance1. Verbal report of fatigue or weakness2. Abnormal heart rate or blood pressure response to

activity

3. Electrocardiographic changes reflecting arrhythmiasor ischemia

4. Exertional discomfort or dyspnea

RELATED FACTORS22

A. Risk for Activity IntoleranceThe risk factors also serve as the related factors for thisdiagnosis.

B. Activity Intolerance1. Bed rest or immobility2. Generalized weakness3. Imbalance between oxygen supply and demand4. Sedentary lifestyle


1. Anemias2. Congestive heart failure3. Valvular heart disease4. Cardiac arrhythmia5. Chronic obstructive pulmonary disease (COPD)6. Metabolic disorder7. Musculoskeletal disorders



••••••


Adult Health


Determine current potential for desired activities, including:• Physical limitations related to illness or surgery• Factors that relate to desired activities• Realistic expectations for actualizing potential for

desired activities• Objective criteria by which specific progress may be

measured (e.g., distance, time, and observable signs orsymptoms such as apical pulse, respiration)

• Previous level of activities the patient enjoyed

Determine internal and external motivators for activities,and record here.

Determine self-care activities the patient should assume.Increase activities as energy levels allow.

Encourage rest as needed between activities. Assistthe patient in planning a balanced rest–activityprogram.

Ensure the patient is getting adequate sleep. See nursingactions for Fatigue.

Monitor and record blood pressure, pulse, and respirationbefore and after activities.

Provides a baseline for planning activities and increasein activities.

Planned rest assists in maintaining and increasing activitytolerance.

Vital signs increase with activity and should return tobaseline within 5 to 7 minutes after activity. Maximaleffort should be greater than or equal to 60 to 80 per-cent over the baseline.


Impaired Physical MobilityThis diagnosis implies that an individual would beable to move independently if something were not lim-iting the motion. Activity Intolerance implies that theindividual is freely able to move but cannot endure oradapt to the increased energy or oxygen demandsmade by the movement or activity.

Self-Care DeficitSelf-Care Deficit indicates that the patient has somedependence on another person. Activity Intoleranceimplies that the patient is independent but is unableto perform activities because the body is unable toadapt to the increased energy and oxygen demandsmade. A person may have a self-care deficit as aresult of activity intolerance.

Ineffective Individual CopingPersons with the diagnosis of Ineffective IndividualCoping may be unable to participate in their usualroles or in their usual self-care because they feelthey lack control or the motivation to do so.

Activity Intolerance, on the other hand, implies thatthe person is willing and able to participate in activ-ities but is unable to endure or adapt to the increasedenergy or oxygen demands made by the movementor activity.

EXPECTED OUTCOME

Will participate in increased self-care activities by [date].(Specify which self-care activities, that is, bathing, feeding,dressing, or ambulation, and the frequency, duration, orintensity of the activity.)

E X A M P L E

Will increase walking by at least 1 block each week for8 weeks.

TARGET DATES

Appropriate target dates will have to be individualizedaccording to the degree of activity intolerance. An appropri-ate range would be 3 to 5 days.



••••••

Encourage progressive activity and increased self-careas tolerated. Schedule moderate increase in activitieson a daily basis (e.g., will walk 10 feet farther eachday).

Assist the patient with self-care activities as needed. Letthe patient determine how much assistance is needed.

Collaborate with health-care providers regarding oxygentherapy.

Collaborate with a physical therapist in establishing anappropriate exercise plan.

Provide for a quiet, nonstimulating environment. Limitnumber of visitors and length of their stay.

Assure adequate dietary input, consider the patient’s foodpreferences and consult with dietitian.

Assist the patient in weight reduction as required.

Teach the patient relationship between nutrition andexercise tolerance, and assist in developing a diet thatis appropriate for nutritional and metabolic needs.(See Chapter 3 for further information.)

Instruct the patient in energy-saving techniques of dailycare (e.g., preparing meals sitting on a high stool ratherthan standing).

Initiate physical therapy and/or occupational therapyearly in admission.

Gradually increases tolerance for activities.

Allows the patient to have some control and choice inplan; helps the patient to gradually decrease theamount of activity intolerance.

Oxygen may be needed for shortness of breath associatedwith increased activity.

Provides most appropriate activities for the patient.

Determine various methods to motivate behavior.

Provides adequate nutrition to meet metabolic demands.

Decreased weight requires less energy.

Assists the patient to learn alternate methods to conserveenergy in ADLs.

Will deter muscle wasting and development of disusesyndrome.


Child Health

May include applicable, according to age/developmental status, the generic components of Adult Health care plan plus thefollowing:


Provides foundation for comprehensive approach toproblem-solving.

A holistic approach offers the greatest likelihood formeeting the client’s desired goal in the safest waypossible.

Emphasizes the role each will have for fostering the suc-cess of the plan.

Developmentally appropriate materials enhance learningand maintain the child’s attention.

Continuity of caregivers fosters trust in the nurse–patientrelationship, which enhances learning.

Monitor factors that are contributing to this problem.

Address relevant pre-existing issues to include issues fortiming of activity, previous level of activity, currentmedical status and how the desired level of activity isto be attained.

*May include the pediatrician and occupational or physi-cal therapist.

Develop, with the child and parents, an activity plan.[Note that plan here.]

Provide learning modules and practice sessions withmaterials suitable for the child’s age and develop-mental capacity (e.g., dolls, videos, or pictures).

Provide for continuity in care by assigning the samenurses for care during critical times for teaching andimplementation.




••••••

Women’s Health


Premature Rupture of Membranes23–25

Assists in reducing fears of expectant parents and increas-ing the likelihood of a good outcome for the pregnancy.

Carefully monitor fetal heart rate to detect cord compres-sion and/or cord prolapse.

Carefully monitor for signs and symptoms of amnionitis.• Check maternal temperature every 4 h.• Evaluate for uterine tenderness at least twice a day.• Check daily leukocyte counts.• Avoid vaginal examinations.

Keep the patient and partner informed, and encouragetheir participation in management decisions.

Explain and provide answers to questions regarding:• Possible preterm delivery• Fetal lung maturity and possible use of corticosteroids

to accelerate fetal lung maturity

Provide comfort measures to decrease intolerance of bedrest:

• Back or body massage• Diversional activities, such as television, reading, or

handicrafts• Bedside commode (if acceptable to treatment plan)

Preterm Labor24–28

● N O T E : Approach to treatment is controversial and depends on practice in yourparticular area.

● N O T E : Although there is disagreement on the definition, the most widely used defini-tion of preterm labor is six to eight contractions per hour or 4 contractions in 20 min-utes associated with cervical change.25

Thoroughly explain to the patient and partner the processof preterm labor.

Discuss options of activity allowed. Provides the parents with information, increases motiva-tion to continue with reduced activity, and allowsinformed choices

● N O T E : This varies, and there is controversy in the literature on the value of bedrest for preterm labor; therefore, look at practice in your area.

Modify expected behavior to incorporate appropriatedevelopmental needs (e.g., allow for shared cards,messages, or visitors to lobby if possible for adoles-cent patients).

Reinforce adherence to regimen with stickers or otherappropriate measures to document progress.

Valuing of the patient’s developmental needs fosters self-esteem and serves as a reward for efforts.

Extrinsic rewards may help symbolize concrete progressand assist in reinforcing appropriate behaviors forachieving goals.


Child Health




••••••

Discuss various treatment possibilities:• Prolonged bed rest or at least a marked reduction in

activity• Intravenous volume expansion (IV therapy)• Tocolytic therapy (IV, oral, or pump)• Use of magnesium sulfate• Use of prostaglandin synthesis inhibitors such as

indomethacin• Use of calcium channel blockers

Carefully monitor those patients receiving tocolytictherapy for:

• Pulmonary edema• Hypokalemia• Hyperglycemia• Shortness of breath• Chest pain• Cardiac dysrhythmia• Electrocardiographic “ischemia” changes• Hypotension

Carefully monitor uterine contractions (strength, quality,frequency, and duration).

Monitor fetal heart rate in association with contractions.

Provide diversional activities for patients on bed rest.

Refer for home monitoring and evaluation if appropriate:• Assess the patient’s ability to identify contractions.• Evaluate the patient’s support system at home.• Assess the patient’s access to health-care provider.

Pregnancy-Induced Hypertension (PIH)29–32

Explain the various screening procedures for PIH to thepatient and partner:

• Blood pressure measurement• Urine checked for protein• Assessment of total and interval weight gain• Signs and symptoms of sudden edema of hands and

face, sudden 5-pound weight gain in 24 to 48 hours,epigastric pain, or spots before eyes or blurred vision

Discuss treatment plan with the patient and partner:• Bed rest on either side (right or left)• Magnesium sulfate therapy• Reduction in noise, visual stimuli, and stress• Careful monitoring of fetal heart rate• Possible sonogram to determine intrauterine growth

rate (IUGR)• Good nutrition with a maximum recommended

daily allowance (RDA) sodium intake of 110 to3300 mg/day

Assess the patient’s support system to determine whetherthe patient can be treated at home.29–32

Assist the family in planning for needed caretaking andhousekeeping activities if the patient is at home.29–32

Increases compliance, decreases cost, and decreasesmaternal stress when she can achieve treatmentat home instead of in an acute care setting.





••••••

Consult with perinatalogist and visiting nurse to imple-ment collaborative care plan.

Ensure that the family knows procedure for obtainingemergency service.

Uncomplicated Pregnancy

Provides opportunity to rest throughout the day andtherefore the ability to maintain as many routine activi-ties as possible. Increases oxygen flow to the uterusand the fetus, thereby reducing the possibility ofpreterm labor and severe fatigue.

A common problem with a new baby is overwhelmingfatigue on the part of the mother. These measures willassist in decreasing the fatigue.


Women’s Health


● N O T E : Even though there are often no complications in pregnancy, it is not unusual,particularly during the last 4 to 6 weeks, to have activities restricted because of edema,bouts with false labor, and fatigue. This fatigue continues after the birth, when themother and father become responsible for the care of a newborn infant 24 hours a day.Discuss with the expectant parents methods of conserving

energy while continuing their daily activities during thelast weeks of pregnancy.

Assist the expectant mother in developing a plan wherebyshe can take frequent (two in the morning, two in theafternoon), short breaks during the work day to:

• Retain energy and reduce fatigue.• Reduce the incident of false labor.• Increase circulation and thus reduce dependent lower

limb edema and increase oxygen to the placenta andfetus.

Assist the expectant parents to plan for the possibility ofreducing the number of hours the woman works duringthe week. Look at the work schedule and talk with theemployer about the possibilities of:

• Working every other day• Working only half-day each day• Working 3 days in the middle of the week, i.e.,

Tuesday, Wednesday, and Thursday, thus, having a4-day weekend to rest

• Job sharing

After DeliveryInstruct the patient in energy-saving activities of daily

care:• Take care of self and baby only.• Let the partner and others take care of housework and

other children.• Let the partner and others take care of the baby for a

prearranged time during the day so the mother canspend quality time with the other children.

• Learn to sleep when the baby sleeps.• Turn off the telephone or turn on the answering

machine.• Have specific times set for visiting of friends or rela-

tives.• If breastfeeding, partner can change the infant and

bring the infant to the mother at night. (The motherdoes not always have to get up and go to the infant.)



••••••

Consider taking the baby to bed with the parent. Newest research shows that taking the baby to bed with themother and father at night for the first few weeks25,31:

• Allows the mother, father, and infant to get more rest.• Provides more time for the baby to nurse, and baby

begins to sleep longer more quickly.• Possibly reduces the incidence of sudden infant death

syndrome (SIDS) because the baby mimics the breath-ing patterns of the mother and father.

• Promotes positive learning and acquaintance activities forthe new parents. Allows the infant to feel more secure,and therefore increases infant-to-parent attachment.


Mental Health


Discuss with the client his or her perceptions of activityappropriate to his or her current capabilities.

If the client estimates a routine that far exceeds currentcapabilities (as with eating disorder clients or clientsexperiencing elated mood):

• Establish appropriate limits on exercise. (The limitsand consequences for not maintaining limits estab-lished should be listed here. If the excessive exercisepattern is related to an elated mood, set limits in amanner that allows the client some activity while notgreatly exceeding metabolic needs until psychologicalstatus is improved.)

• Begin the client slowly (e.g., with stretching exercisefor 15 minutes twice a day).

• Note client’s goals here.• As physical condition improves, gradually increase

exercise to 30 minutes of aerobic exercise onceper day.

• Discuss with the client appropriate levels of exer-cise considering his or her age and metabolicpattern.

• Discuss with the client the hazards of overexercise.• Establish a reward system for clients who maintain the

established exercise schedule (the schedule for theclient should be listed here with the reinforcers that areto be used).

• Stay with the client while he or she is engaged inappropriate exercise.

• Develop a schedule for the client to be involved in anoccupational therapy program to assist the client inidentifying alternative forms of activity other than aer-obic exercise.

Provides an understanding of the client’s worldview sothat care can be individualized and interventions devel-oped that are acceptable to both the nurse and theclient.33

Negative reinforcement eliminates or decreases behav-ior.34 Because of the high energy level, elated clientsneed some large motor activity that will dischargeenergy but does not present a risk for physical harm.35

Goals need to be achievable to promote the sense ofaccomplishment and positive self feelings, which willin turn increase motivation.33

A regimen that provides positive cardiovascular fitnesswithout risk of overexertion.37

Overexertion can decrease benefits of exercise by increas-ing risk for injury.36


Interaction with the nurse can provide positivereinforcement.34

Promotes accurate perception of body size, nutrition, andexercise needs.




••••••


Mental Health


• Limit number of walks off the unit to accommodateclient’s weight, level of exercise on the unit, and physi-ology (the frequency and length of the walk should belisted here).

For further information related to eating disorder clients,see Imbalanced Nutrition, Less Than BodyRequirements (Chapter 3).

If the client’s expectations are much less than currentcapabilities (as with a depressed or poorly motivatedclient), implement the following actions:

• Establish very limited goals that the client can accom-plish (e.g., a 5-minute walk in a hallway once a day orwalking in the client’s room for 5 minutes). The goalestablished should be listed here.

• Establish a reward system for achievement of goals(the reward program should be listed here with a list ofitems the client finds rewarding).

• Develop a schedule for the client to be involved in anoccupational therapy program (note schedule here).

• Establish limits on the amount of time the client canspend in bed or in his or her room during wakinghours (establish limits the client can achieve, andnote limits here).

• Stay with the client during exercise periods and timeout of the room until the client is performing thesetasks without prompting.

• Provide the client with firm support for initiating theactivity.

• Place a record of goal achievement where the client cansee it, and mark each step toward the goal with areward marker.

• Provide positive verbal reinforcement for goal achieve-ment and progress.

For further information about clients with depressedmood, refer to Ineffective Individual Coping(Chapter 11).

Monitor effects current medications may have on activitytolerance, and teach the client necessary adjustments.

Schedule time to discuss plans and special concerns withthe client and the client’s support system. This couldinclude teaching and answering questions. Scheduledaily during initial days of hospitalization and onelonger time just before discharge. Note schedule timesand person responsible for this.

Goals need to be achievable to promote sense of accom-plishment and positive self feelings, which will in turnincrease motivation.33


Provides the client with opportunity to improve self-helpskills while engaged in a variety of activities.

Exercise raises levels of endorphins in the brain, whichhas a positive effect on depression and general feelingof well-being.35,37

Interaction with the nurse can provide positivereinforcement.34

Attention from the nurse can provide positive reinforce-ment and increase the client’s motivation to accomplishgoal.

Provides concrete evidence of goal attainment and moti-vation to continue these activities that will promotewell-being.

Psychotropic medications may cause postural hypoten-sion, and the client should be instructed to changeposition slowly.

Recognizes the reciprocity between the client’s illnessand the family context.38



••••••

Collaborate with the client to determine factors that con-tribute to activity intolerance (pain, shortness of breath).Address those factors specifically as appropriate.

Determine, with the assistance of the patient, particulartime periods of highest energy, and plan careaccordingly.

Teach the patient to monitor pulse before, during, andafter activity.

Refer the patient to occupational therapy and physicaltherapy for determination of a progressive activityprogram.

Establish goals that can be met in a short time frame(daily or weekly).

Use positive feedback for incremental successes.

Monitor for signs of potential complications related todecreased activity level, such as problems with skinintegrity, elimination complications, and respiratoryproblems.

Individualizes care.

Maximizes potential to participate in or complete carerequirements successfully.

Promotes self-monitoring and provides means of deter-mining progress across care settings.

Collaboration ensures a plan that will result in activity formaximum effect.

Provides motivation to continue program.37

Reinforces the older adult’s potential to have effortsproduce positive outcomes. Enhances sense of self-efficacy.40

Older adults are highly susceptible to the negativephysiologic and psychological consequences ofimmobility.40

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized with aging clients.


Home Health

● N O T E : Interventions for Adult Health apply with the addition of the followinginterventions:


Monitor the safety of the home environment for a clientwith activity intolerance. Educate client/caregiver ofpossible environmental modifications needed toinclude:

• Wider doors• Lever style door handles instead of doorknobs• Bathroom rails• Removal of clutter• Functional arrangement of furniture• Flooring that facilitates use of mobility assistive devices• Phones that are readily accessible

Teach the client and family appropriate monitoring ofcauses, signs, and symptoms of risk for or actual activ-ity intolerance:

• Prolonged bed rest• Circulatory or respiratory problems• New activity• Fatigue• Dyspnea• Pain

Promotes safety.

Provides baseline for prevention and/or early inter-vention.




••••••

• Vital signs (before and after activity)• Malnutrition• Previous inactivity• Weakness• Confusion


• Progressive exercise to increase endurance• Range of motion (ROM) and flexibility exercises• Treatments for underlying conditions (cardiac, respira-

tory, musculoskeletal, circulatory, etc.)• Motivation• Assistive devices as required (walkers, canes, crutches,

wheelchairs, exercise equipment, etc.)• Adequate nutrition• Adequate fluids• Stress management• Pain relief• Prevention of hazards of immobility• Changes in occupations or family or social roles• Changes in living conditions• Economic concerns

Assist the client and family to set criteria to help themdetermine when calling a physician or other interven-tion is required.

Monitor the client need for resources and refer appropri-ately. Consider possible needs such as:

• Assistive devices• Mobility devices• Security devices

Lifestyle changes require sufficient support to achieve.

Provides additional support for the client.

Provides additional support for the client.


Home Health


AIRWAY CLEARANCE, INEFFECTIVE

DEFINITION22

Inability to clear secretions or obstructions from the respira-tory tract to maintain a clear airway.


1. Dyspnea2. Diminished breath sounds3. Orthopnea4. Adventitious breath sounds (rales, crackles, rhonchi,

and wheezes)5. Cough, ineffective or absent6. Sputum7. Cyanosis8. Difficulty vocalizing9. Wide-eyed

10. Changes in respiratory rate and rhythm11. Restlessness

RELATED FACTORS22

1. Environmentala. Smokingb. Smoke inhalationc. Second-hand smoke

2. Obstructed airwaya. Airway spasmb. Retained secretionsc. Excessive mucusd. Presence of artificial airwaye. Foreign body in airwayf. Secretions in the bronchig. Exudate in the alveoli


Airway Clearance, Ineffective 293

••••••

bon dioxide are not appropriately exchanged at thealveolar–capillary level. Air has been able to passthrough clear air passages, but a problem arises atthe cellular level.

Deficient Fluid VolumeWhen fluid volume is insufficient to assist in liquefyingthick, tenacious respiratory tract secretions, DeficientFluid Volume then becomes the primary diagnosis. Inthis instance, the patient would be unable to expecto-rate the secretions effectively no matter how hard heor she tried, and Ineffective Airway Clearance wouldresult.

PainIf pain is sufficient to prevent the patient from cough-ing to clear the airway, then Ineffective AirwayClearance will result secondary to the pain.

EXPECTED OUTCOME

Will have an open, clear airway by [date].Respiratory rate and rhythm will be within normal

limits by [date].Client will clear airway independently by [date].

TARGET DATES

Ineffective airway clearance is life-threatening; therefore,progress toward meeting the expected outcome should beevaluated at least on a daily basis.


The various ways of measuring lung volume and capacityare summarized and defined in Table 5.2.

3. Physiologica. Neuromuscular dysfunctionb. Hyperplasia of the bronchial wallsc. Chronic obstructive pulmonary diseased. Infectione. Asthmaf. Allergic airways


1. Adult respiratory distress syndrome (ARDS)2. Pneumonia3. Cancer of the lung4. Chronic obstructive pulmonary disease (COPD)5. Congestive heart failure6. Cystic fibrosis7. Inhalation injuries8. Neuromuscular diseases


Ineffective Breathing PatternThis diagnosis implies an alteration in the rate,rhythm, depth, or type of respiration, such as hyper-ventilation or hypoventilation. These patterns are noteffective in supplying oxygen to the cells of the bodyor in removing the products of respiration. However,air is able to move freely through the air passages. InIneffective Airway Clearance, the air passages areobstructed in some way.

Impaired Gas ExchangeThis diagnosis means that air has been inhaledthrough the air passages but that oxygen and car-

T A B L E 5 . 2 Lung Capacities and Volumes

AVERAGE VALUE, ADULTMEASUREMENT MALE RESTING (ML) DEFINITION

Tidal volume (TV)

Inspiratory reserve volume (IRV)

Expiratory reserve volume (ERV)

Residual volume (RV)

Total lung capacity (TLC)

500

3100

1200

1200

6000

Amount of air inhaled or exhaled with each breath

Amount of air that can be forcefully inhaled after anormal tidal volume inhalation

Amount of air that can be forcefully exhaled aftera normal tidal volume exhalation

Amount of air left in the lungs after a forcedexhalation

Maximum amount of air that can be contained inthe lungs after a maximum inspiration: TLC �TV � IRV � ERV � RV




••••••


Adult Health


Maintain appropriate emergency equipment as dictated bythe situation (e.g., suctioning apparatus).

Monitor respiratory rate, depth, and breath sounds at leastevery 4 hours.

Collaborate with the health-care team in regard to obtain-ing arterial blood gasses.

Initiate pulmonary toilet. Turn, cough, deep breathingevery 2 hours.

Turn every 2 hours. Perform chest physiotherapy every 2hours while awake at [times]. Teach the family theseprocedures.

Maintain adequate hydration.

Assure adequate pain control.

Teach patient splinting techniques.

Suction as needed.

Monitor oxygen saturation, arterial blood gases, respira-tory rate, breath sounds.

Administer medications (e.g., bronchodilator, mucolytics,and expectorants) as prescribed.

Assist the patient in coughing, huffing, and breathingefforts to make these more productive.

Have the patient demonstrate proper coughing andbreathing techniques twice a day.

Basic safety precautions.

Basic indicators of respiratory effort.

Assists in determining changes in ventilatory status.

Facilitates postural drainage. Chest PT loosens secre-tions for expectoration. Teaching the family allowsthem to participate in care under supervision andpromotes continuation of the procedure afterdischarge.

Inhibits formation of mucous plugs

Increases efficacy of cough. Decreases pain that occurswith cough after surgery.

Determines efficacy of plan of care and allows for adjust-ment of plan as necessary.

Promotes air circulation.

Deep breathing and diaphragmatic breathing allow forgreater lung expansion and ventilation as well as amore effective cough.

T A B L E 5 . 2 Lung Capacities and Volumes (continued from page 293)

AVERAGE VALUE, ADULTMEASUREMENT MALE RESTING (ML) DEFINITION

Vital capacity (VC)

Inspiratory capacity (IC)

Functional residual capacity (FRC)

4800

3600

2400

Maximum amount of air that can be expired aftera maximum inspiration: VC � TV � IRV � ERVShould be 80% of TLC

Maximum amount of air that can be inspired aftera normal expiration: IC � TV � IRV

Volume of air remaining in the lungs after a normaltidal volume expiration: FRC � ERV � RV



••••••

Assist the patient with clearing secretions from mouthor nose by:

• Providing tissues• Using gentle suctioning if necessary

Assist the patient with oral hygiene at least every 4 hourswhile awake at [times]:

• Lubricate lips with a moisturizing agent.• Do not allow the use of oil-based products around

the nose.

Discuss with the patient the importance of maintainingproper position to include:

• Side-lying position while in bed

Promote rest and relaxation by scheduling treatments andactivities with appropriate rest periods.

Confer with appropriate consultations as needed (e.g.,respiratory therapy or physical therapy).

Provide for appropriate follow-up by scheduling appoint-ments before dismissal.

Removes tenacious secretions from airways.

Oral hygiene clears away dried secretions and freshensthe mouth. Oil-based products may obstruct breathingpassages.

Facilitates expansion of the diaphragm; decreases proba-bility of aspiration.

Avoids overexertion and worsening of condition.

Promotes cost-effective use of resources, and promotesfollow-up care.


Child Health


Monitor patient factors that relate to ineffective airwayclearance, including:

• Feeding tolerance or intolerance• Allergens• Emotional aspects• Stressors of recent or past activities• Congenital anomalies• Parental anxieties• Infant or child temperament• Abdominal distention• Related vital signs, especially heart rate• Diaphragmatic excursion• Retraction in respiratory effort• Choking, coughing• Flaring of nares• Appropriate functioning of respiratory equipment

Provide appropriate attention to suctioning and relatedrespiratory maintenance:

• Appropriate size for catheter as needed• Appropriate administration of humidified oxygen as

ordered by physician• Appropriate follow-up of blood gases• Documentation of oxygen administration, characteris-

tics of secretions obtained by suctioning, and vitalsigns during suctioning, reporting apical pulse less than70 or more than 149 beats per minute for an infant orless than 90 or more than 120 beats per minute for ayoung child.

Provides an individualized data baseline that facilitatesindividualized care planning.

Ensures basic maintenance of airway and respiratoryfunction. Gives priority attention to the child’s statusand developmental level.




••••••


Child Health


Encourage the parent’s input in planning care for thepatient, with attention to individual preferences whenpossible.

Provide health teaching as needed based on assessmentand the child’s situation.

Plan for appropriate follow-up with health teammembers.

Reduce apprehension by providing comforting behaviorand meeting developmental needs of the patient andfamily.

Allow for diversional activities to approximate toleranceof the child.

Encourage the family members to assist in care of thepatient, with use of return-demonstration opportunitiesfor teaching required skills.

Provide for appropriate safety maintenance, especiallywith oxygen administration (no smoking), andappropriate precautions for age and developmentallevel.

Allow ample time for parental mastery of skills identifiedin care of the child.

Promotes family empowerment, and thus promotes thelikelihood of more effective management of therapeuticregimen after discharge.

Allows timely home care planning, family time to askquestions, practicing of techniques, etc. before dis-charge. Assists in reducing anxiety, and promotes con-tinuance of the therapeutic regimen.

Provides for long-term support and effective managementof the therapeutic regimen.

Sensitivity to individual feelings and needs builds trust inthe nurse–patient–family relationship.

Realistic opportunities for diversion will be chosen basedon what the patient is capable of doing and what willleave the patient feeling refreshed and renewed forhaving participated.

Return-demonstration provides feedback to evaluateskills and serves to provide reinforcement in a support-ive environment. Involvement of the parents alsosatisfies the emotional needs of both the parents andthe child.

Appropriate safety measures must be taken with the useof combustible potentials whose use outside of pre-scribed parameters may be toxic.

Greater success in compliance and confidence isafforded by providing ample time for skills thatrequire mastery.

Women’s Health

● N O T E : The following nursing actions pertain to the newborn infant in the deliveryroom immediately following delivery. See Adult Health and Home Health for actionsrelated to the mother.


Evaluate and record the respiratory status of the newborninfant:

• Suction and clear mouth and pharynx with bulb syringe.• Avoid deep suctioning if possible.

Continue to evaluate the infant’s respiratory status, and actif necessary to resuscitate. Depending on the infant’sresponse, the following nursing measures can be taken:

• Administer warm, humid oxygen with a face mask.• If no improvement, administer oxygen with bag and

mask.

Basic measures to clear the newborn’s airway. Deep suc-tioning would stimulate reflexes that could result inaspiration.

Basic protocol for the infant who has difficulty immedi-ately after birth.



••••••

Mental Health

Care plan for Adult Health can be utilized as a foundation with the following considerations for psychiatric clients:


Collaborate with the physician for possible use of salinegargles or anesthetic lozenges for sore throats (reportall sore throats to the physician, especially if the clientis receiving antipsychotic drugs and in the absence ofother flu or cold symptoms).

Remind the client to chew food well, and sit with theclient during mealtime if cognitive functioning indi-cates a need for close observation. [Note any specialadaptations here (e.g., soft foods, observation duringmeals, etc.)]

These commonly used medications can cause blooddyscrasias that present with the symptoms of sorethroat, fever, malaise, unusual bleeding, and easy bruis-ing. Early intervention is important for patient safety.41

Provides safety for the client with alterations of mentalstatus.

Gerontic Health

● N O T E : Aging adults tend to decrease their fluid intake, which can contribute to thedevelopment of ineffective airway clearance. Consider this issue as a part of initial andongoing assessment.



• If no improvement, be prepared for:• Endotracheal intubation• Ventilation with positive pressure• Cardiac massage• Transport to neonatal intensive care unit


Teach and facilitate pulmonary hygiene measures withthe client and caregivers:

• Coughing and deep-breathing exercises every 2 hourson [odd/even] hour

• Ensuring adequate hydration (monitor intake andoutput)

• Clearing the bronchial tree by controlled coughing• Decreasing viscosity of secretions via humidity and

fluid balance• Postural drainage• Learning stress management• Ensuring adequate nutritional intake• Learning diaphragmatic breathing• Administering pain relief• Beginning progressive ambulation (avoiding fatigue)• Maintaining position so that danger of aspiration is

decreased• Maintaining body position to minimize work of breath-

ing and cleaning airway• Ensuring adequate oral hygiene• Clearing secretions from throat• Suctioning as needed

Basic pulmonary hygiene prevents further airwayproblems.



••••••



Teach the client and family appropriate monitoring ofsigns and symptoms of ineffective airway clearance:

• Cough (effective or ineffective)• Sputum• Respiratory status (cyanosis, dyspnea, and rate)• Abnormal breath sounds (noisy respirations)• Nasal flaring• Intercostal, substernal retraction• Choking, gagging• Diaphoresis• Restlessness, anxiety• Impaired speech• Collection of mucus in mouth


• Eliminating smoking• Treating fear or anxiety• Treating pain• Performing pulmonary hygiene:

• Clearing the bronchial tree by controlled coughing• Decreasing viscosity of secretions via humidity and

fluid balance• Postural drainage

• Learning stress management

Provides for early recognition and intervention forproblem.

Provides basic information for the client and family thatpromotes necessary lifestyle changes.


Gerontic Health


• Keeping area free of dust and potential allergens orirritants

Provide small, frequent feedings during periods ofdyspnea.

Instruct the patient regarding early signs of respiratoryinfections (e.g., increased amount or thickness ofsecretions, increased cough, or changes in color ofsputum produced).

Facilitate increased mobility, as tolerated, on a dailybasis. [Note plan for this client here.]

Teach the patient to complete prescribed course of antibi-otic therapy.

Monitor for the use of sedative medications that candecrease the level of alertness and respiratory effort.

Collaborate with the physician regarding the use of coughsuppressants and mucolytics.

Conserves energy and promotes ventilation efforts.

Early recognition of signs of infection promotes earlyintervention and avoidance of severe infection.

Mobility helps increase rate and depth of respiration aswell as decreasing pooling of secretions.

Because of economic factors, patients commonly stoptherapy before the designated time frame, “saving” themedication for possible future episodes.

These medications can decrease the level of alertness andrespiratory effort.

Decreases episodes of persistent, nonproductivecoughing.


Autonomic Dysreflexia, Risk For and Actual 299

••••••

• Ensuring adequate nutritional intake• Learning diaphragmatic breathing• Administering pain relief• Beginning progressive ambulation (avoiding fatigue)• Maintaining position so that danger of aspiration is

decreased• Maintaining body position to minimize work of breath-

ing and cleaning airway• Ensuring adequate oral hygiene• Clearing secretions from throat• Suctioning as needed• Keeping area free of dust and potential allergens or irri-

tants• Ensuring adequate hydration (monitor intake and

output)

Teach the client and family purposes, side effects, andproper administration techniques of medications.


Teach the family basic cardiopulmonary resuscitation(CPR).

Consult with or refer to appropriate assistive resourcesas indicated.

Locus of control shifts from nurse to the client and fam-ily, thus promoting self-care.

Provides additional support for the client and family,and uses already available resources in a cost-effectivemanner.

AUTONOMIC DYSREFLEXIA,RISK FOR AND ACTUAL

DEFINITIONS22

Risk for Autonomic Dysreflexia Risk for life-threateninguninhibited response of the sympathetic nervous system,postspinal shock, in an individual with a spinal cordinjury/lesion at T6* or above.

Autonomic Dysreflexia Life-threatening uninhibitedsympathetic response of the nervous system to a noxiousstimulus after a spinal cord injury at T7 or above.


A. Risk for Autonomic DysreflexiaAn injury or lesion at T6 or above and at least one of thefollowing noxious stimuli:1. Neurologic stimuli

a. Painful or irritating stimuli below level of injury2. Urologic stimuli

a. Bladder distentionb. Detrusor sphincter dyssynergia

c. Bladder spasmd. Instrumentation or surgerye. Epididymitisf. Urethritisg. Urinary tract infectionh. Calculii. Cystitisj. Catheterization

3. Gastrointestinal stimulia. Bowel distentionb. Fecal impactionc. Digital stimulationd. Suppositoriese. Hemorrhoidsf. Difficult passage of fecesg. Constipationh. Enemai. Gastrointestinal system pathologyj. Gastric ulcersk. Esophageal refluxl. Gallstones

4. Reproductive stimulia. Menstruationb. Sexual intercourse


*Has been demonstrated in patients with injuries at T7 and T8.



••••••

c. Pregnancyd. Labor and deliverye. Ovarian cystf. Ejaculation

5. Musculoskeletal–integumentary stimulia. Cutaneous stimulation (e.g., pressure ulcer,

ingrown toenail, dressings, burns, rash)b. Pressure over bony prominences or genitaliac. Heterotrophic boned. Spasme. Fracturesf. Range-of-motion (ROM) exercisesg. Woundsh. Sunburn

6. Regulatory stimulia. Temperature fluctuationsb. Extreme environmental temperatures

7. Situational stimulia. Positioningb. Drug reactions (e.g., decongestants, sympath-

omimetics, vasoconstrictors, narcotic withdrawal)c. Constrictive clothing (e.g., straps, stockings, shoes)d. Surgical procedure

8. Cardiac and/or pulmonary problemsa. Pulmonary embolib. Deep vein thrombus

B. Autonomic Dysreflexia1. Pallor (below the injury)2. Paroxysmal hypertension (sudden periodic elevated

blood pressure where systolic pressure is more than140 mm Hg and diastolic is more than 90 mm Hg)

3. Red splotches on skin (above the injury)4. Bradycardia or tachycardia (pulse rate of less than

60 or more than 100 beats per minute)5. Diaphoresis (above the injury)6. Headache (a diffuse pain in different portions of the

head and not confined to any nerve distribution area)7. Blurred vision8. Chest pain9. Chilling

10. Conjunctival congestion11. Horner’s syndrome (contraction of the pupil, partial

ptosis of the eyelid, enophthalmos, and sometimesloss of sweating over the affected side of the face)

12. Metallic taste in mouth13. Nasal congestion14. Paresthesia15. Pilomotor reflex (gooseflesh formation when skin is

cooled)

RELATED FACTORS22

A. Risk for Autonomic DysreflexiaThe risk factors also serve as the related factors.

B. Autonomic Dysreflexia1. Bladder distention2. Bowel distention3. Lack of patient and caregiver knowledge4. Skin irritation


1. Spinal cord injury at T7 or above


Decreased Cardiac OutputDysreflexia occurs only in spinal cord–injuredpatients and represents an emergency situationthat requires immediate intervention. DecreasedCardiac Output may be suspected because ofthe changes in blood pressure or arrhythmias42,43;but, if the patient has a spinal cord injury at T7or above, Autonomic Dysreflexia should be con-sidered first.

Impaired Skin IntegrityOccasionally symptoms of Autonomic Dysreflexia areprecipitated by skin lesions such as pressure soresand ingrown or infected nails.44 If the patient has aspinal cord injury at T7 or above in combination withImpaired Skin Integrity, the nurse must be extremelyalert to the possible development of AutonomicDysreflexia. In addition, one of the defining character-istics of Autonomic Dysreflexia is red splotches, whichcould lead to a misdiagnosis of Risk for ImpairedSkin Integrity.

Urinary RetentionDysreflexia should be suspected in patients withspinal cord injuries at T7 or above who experiencebladder spasms, bladder distention, or untowardresponses to urinary catheter insertion or irriga-tion.44,45 Bowel distention or rectal stimulation mayalso lead to Dysreflexia.

EXPECTED OUTCOME

Will actively cooperate in care plan to prevent develop-ment of dysreflexia by [date].

Will verbalize understanding of the triggers ofDysreflexia by [date].

Vital signs are within normal limits by [date].Will have noncompromised bowel and/or bladder

function by [date].

TARGET DATESAutonomic Dysreflexia is a life-threatening response. Forthis reason, the target date should be expressed in hours ona daily basis.



••••••


Adult Health


Locate source that may have triggered dysreflexia (e.g.,bladder distention [76 to 90 percent of all instances],bowel distention [8 percent of all instances]),46–48 frac-tures, acute abdomen, pressure ulcers, skin irritants, orother stimulation below the level of the spinal cordinjury.

Remove the offending source. Empty bladder slowlywith a straight catheter (do not use Credé’s maneu-ver or tap bladder46,47), or manually remove impactedfeces from the rectum as soon as possible. Exer-cise caution if symptoms worsen with digitaldisimpaction.

Ensure indwelling catheter maintains patency at leastevery 4 hours. [Note times here.]

Notify the health-care team regarding the administrationof emergency antihypertensive therapy.

Keep the patient warm; avoid chilling at all times.

Monitor intake and output every hour for 48 hours, thenevery 2 hours for 48 hours; then every 4 hours. [Notetime schedule and dates here.]

Turn the patient every 2 hours on [odd/even] hour; keepin anatomic alignment.

Perform ROM (active or passive) every 4 hours whileawake at [times]. Pad bony prominences.

Instruct the patient on isotonic exercises. Encourage thepatient to perform isotonic exercises at least every 2hours on [odd/even] hour.

Instruct on bladder and bowel conditioning. Monitorfor bladder and bowel distention every 4 hours at[times].

Catheterize as necessary; use rectal tube if not contraindi-cated to assist with flatus reduction.

Provide appropriate skin care each time the patient isturned. Monitor skin integrity at least once per shiftat [times].

Ensure and educate patient regarding devising a diet thatmeets recommended daily requirements for nutrients,fiber, and fluids.

Involve the family in care such as positioning, feeding,and exercising.

Align the family with community resources. Make refer-rals as soon as possible after admission.

Finding precipitating causes prevents worsening ofcondition and allows further prevention of dysreflexia.

Alleviates precipitating causes.

Facilitates lowering of blood pressure

Decreases sensory nervous stimulation.

Monitors adequate functioning of bowel and bladder,which are common causative factors for dysreflexia.

Alleviates potential precipitating causes.

Alleviates precipitating causes; stimulates circulationand muscular activity; decreases incidence of pressureulcers.

Increases circulation and prevents complications ofimmobility.

Eliminates the two primary precipitating causes.

Addresses potential precipitating causes.

Prevents and monitors for pressure ulcers.

Assists in avoiding constipation.

Assists in teaching and preparing of the family forhome care.

Provides long-range support for the patient and family.




••••••


Child Health

● N O T E : Recognizing the pattern is critical as encephalopathy and shock willoften ensue.


Monitor for contributing factors, esp. bladder distentionand provide intervention as needed.

*Drain the bladder slowly to avoid sudden change inpressure.

Administer medications as required to help controlthe blood pressure at appropriate levels for age andweight

*Antihypertensives are administered IV initially andthen PO when stabilization is reached for main-tenance. Antispasmodics may also be admin-istered.

Monitor the pulse as needed and blood pressure every5 minutes until stable. Determine parameters for thepatient according to the norms for age, site, andcondition.

Monitor the family’s understanding and perception ofdysreflexia. Ensure that proper attention is paid tothe family’s needs for support during this emergencyphase.

Teach the patient, to the extent he or she is capable,and the family routine for care, including the pre-vention of infection (particularly urinary and integu-mentary).

Monitor for latex allergy risk because of multipleurinary catheterizations.

Offers anticipatory guidance for plan with definitiveaction for most likely cause.

Assists in preventing seizures, and provides appropriateintervention to maintain pressure within desiredranges.49

Basic monitoring for initial indications of problem devel-opment.

Assists in preventing misunderstandings and in identify-ing learning needs.

Education enhances care and provides an opportunityfor care to be practiced in a supportive environment.

Frequent catheterization with latex supplies increasesthe risk for allergy.49

Women’s Health

● N O T E : The same nursing diagnosis pertains to Women’s Health as to Adult Health.The following precautions should be taken when the victim is pregnant.


Position the patient to prevent supine hypotension by:• Placing the patient on her left side if possible.• Using a pillow or folded towel under the right hip to

tip to left.• If neck injury is suspected, placing the patient on a

back board and then tipping the board to the left.

Start an intravenous line for replacement of lost fluidvolume.

Monitor fetal status continuously. Monitor for uterinecontractions at least once per hour.

Keeps the weight of the uterus off the inferior vena cava.

The pregnant woman has 50 percent more bloodvolume and her vital signs may not change untilthere is a 30 percent reduction in circulating bloodvolume.

Basic data needed to ensure positive outcome.



••••••

Mental Health

The expected outcomes and nursing actions for the mental health client are the same as those for the adult patient.

Gerontic Health

The nursing actions for the gerontic patient are the same as those for Adult Health.

Home Health

● N O T E : The interventions listed for autonomic dysreflexia are preventive in nature.Should this condition develop in the home setting, emergency health care should besought immediately.


Teach the client, family, and potential caregivers meas-ures to prevent Autonomic Dysreflexia47–49:

• Bowel and bladder routines• Prevention of skin breakdown (e.g., turning, transfer,

or prevention of incontinence)• Use and care of indwelling urinary catheter• Prevention of infection

Assist the client and family in identifying signs andsymptoms of Autonomic Dysreflexia47:

• Teach the family how to monitor vital signs and howto recognize tachycardia, bradycardia, and paroxysmalhypertension.

• Assist the client and family in identifying emergencyreferrals:• Physician• Emergency room• Emergency medical system

• Educate the client, family members, and potential care-givers about immediate elimination of the precipitatingstimuli.

• When an episode occurs, instruct the family and care-givers to place the head of the patient’s bed to anupright position.

• Assist the client in obtaining necessary equipment todrain the bladder or remove impactions at home.

• Educate clients at risk for dysreflexia to be alert forsigns and symptoms of Autonomic Dysreflexia duringsexual encounters. Preparation for sexual intercourseshould include a bowel and bladder check and discon-necting urinary drainage systems.

Basic care techniques that can assist in preventing theoccurrence of dysreflexia. Promotes sense of controland autonomy.

Provides for early recognition and intervention for prob-lem.

Occurrence of this diagnosis is an emergency. This infor-mation provides the family with a sense of security byproviding routes to and numbers of readily availableemergency assistance.

Other treatments will not be effective until the stimulusis removed.

Decreases blood pressure and promotes cerebral venousreturn.

Allows for immediate removal of precipitating stimulus.




••••••

BED MOBILITY, IMPAIREDDEFINITION22

Limitation of independent movement from one bed positionto another.


1. Impaired ability to turn side to side2. Impaired ability to move from supine to sitting or sitting

to supine3. Impaired ability to “scoot” or reposition self in bed4. Impaired ability to move from supine to prone or prone

to supine5. Impaired ability to move from supine to long sitting or

long sitting to supine

RELATED FACTORS22

To be developed.


1. Any condition causing paralysis2. Arthritic conditions3. Major chest or abdominal surgeries4. Malnutrition5. Cachexia6. Trauma7. Depression


Impaired Physical MobilityImpaired Bed Mobility is a more specific diagnosisthan Impaired Physical Mobility. Certainly, an individ-ual would have both diagnoses if he or she could notchange his or her position in bed. Impaired BedMobility would be the priority diagnosis.

Activity IntoleranceThis diagnosis refers to problems that developwhen a person is engaged in activities. The personwith this diagnosis would be able to move freelywhile in bed.

Impaired WalkingThis diagnosis is specific to the act of walking.This diagnosis, like Impaired Bed Mobility, couldbe considered a subset of Impaired PhysicalMobility.

EXPECTED OUTCOME

Will freely move self in bed by [date].

TARGET DATES

Improvement in mobility will require long-term interven-tion; therefore, a feasible date for evaluating progresstoward the outcome would be 2 weeks.


Home Health


Teach the patient and family appropriate uses and sideeffects of medications as well as proper administrationof the medications.

Obtain available wallet-sized card that briefly outlineseffective treatments in an emergency situation.50 Havethe client carry this card with him or her at all times.Family members must be familiar with content andlocation of card.


● N O T E : Labeled a Treatment Card, this card contains information related to patho-physiology, common signs and symptoms, stimuli that trigger Autonomic Dysreflexia,problems, and recommended treatment.


Bed Mobility, Impaired 305

••••••


Adult Health


Identify and provide assistive devices (e.g., trapeze).

Initiate supportive therapies:• Maintain adequate nutrient intake• Confer with physical therapy and/or occupational ther-

apy to devise plan for muscle strengthening

Will facilitate mobility in bed.

Child Health


Monitor for contributing factors within the client’s devel-opmental capacity.

Identify priorities of basic physiologic functions to bestabilized and considered as related to movement:

• Respiratory• Cardiovascular• Neurologic• Orthopedic• Urologic• Integumentary

Determine need for assistive devices.

Determine teaching needs regarding mobility forthe client, family, or staff assisting with mobilityactivities.

Coordinate efforts for other health team members.

Determine the need for restraints of the client, and seekappropriate orders if indicated.

Provide ongoing assessment with documentation of theclient’s tolerance of mobility activities as often as thepatient’s status dictates.

Provide developmentally appropriate diversionalactivities.

Safeguard areas of vulnerability while movementoccurs, such as burns, traumatized limb, or surgicalsite.

Honor the child’s ability to safely carry out activities asappropriate.

A complete ongoing assessment provides the primarydatabase for individualization of care.

Stabilization of basic physiologic status must be consid-ered for tolerance and safety.

Realistic support may depend on orthotics, braces,splints, or other mechanical devices for safety.

Appropriate planning will offer greater likelihood of safeand consistent efforts.

The nurse is best suited to provide consistent and safeplanning of care with all health team members.

Appropriate attention to safety is paramount.

Ongoing timely assessment ensures safety and preventsinjury.

Engagement in preferred activities enhances the likeli-hood of cooperation by the client.

Caution to entire body will best help prevent furtherinjury.

Supports autonomy.49

Women’s Health

The nursing actions for Women’s Health are the same as those for Adult Health.(care plan continued on page 306)



••••••

Home Health


Assist the client in obtaining necessary durable medicalequipment to facilitate independent movement andassisted movement (e.g., over-bed trapeze, hospital bedwith siderails, and sliding board).

Educate the client, family, and caregivers in the correctuse of equipment to facilitate independent movementand assisted movement (e.g., over-bed trapeze, hospitalbed with siderails, and sliding board).

Instruct the caregivers in the proper use of draw sheetsto reposition the client rather than dragging the clientor using poor body mechanics to assist in reposi-tioning.

Assist the client in obtaining necessary supplies to pre-vent thrombus formation due to immobility, such asthromboembolic stockings or pneumatic devices.

Encourage ROM exercises to promote strength.

Teach the client regarding proper body mechanics.

As the client begins to progress in his or her effortstoward independent mobility, the nurse provides mini-mal assistance from the weak side, supporting theunaffected side.

Minimizes risk of injury to both the client and caregiver.

Prevents deep vein thrombosis.

Improves circulation and motor tone.

Prevents further injury.

Promotes independence while protecting from furtherinjury.


Mental Health

Refer to Adult Health for interventions and rationales related to this diagnosis.

Gerontic Health


Consult with occupational therapist and physical therapistfor adaptive equipment to support the client while inbed (such as trapeze, transfer enabler, and foam sup-port blocks).

Ensure that adaptive equipment is maintained in properfunctioning order.

Implement pressure-reducing devices, such as therapeuticmattresses or mattresses with removable sections, toprevent problems with skin integrity.

Schedule turning and position changes according to theclient’s tolerance to pressure. (Determined for eachindividual based on general condition and risk forpressure ulcer development.)

Initiate ROM interventions (active or passive) on a dailybasis.

Facilitates mobility efforts the client may be able to sup-port.51

Ensures that safety needs are met.

Older adults are at high risk for pressure ulcers becauseof skin fragility, changes in sensation, and alterednutrition.52

Depending on the individual client’s health status, turningat the usually prescribed interval of q 2 h may not besufficient to reduce risk for pressure ulcers.52

Maintains joint mobility and prevents contractures.53


Breathing Pattern, Ineffective 307

••••••

BREATHING PATTERN, INEFFECTIVE

DEFINITION22

Inspiration and/or expiration that does not provide adequateventilation.21


1. Decreased inspiratory and/or expiratory pressure2. Decreased minute ventilation3. Use of accessory muscles to breathe4. Nasal flaring5. Dyspnea6. Altered chest excursion7. Shortness of breath8. Assumption of three-point position9. Pursed-lip breathing

10. Prolonged expiration phase11. Increased anterior–posterior chest diameter12. Respiratory rate (infants, �25 or �60; ages 1 to 4,

�20 or �30; ages 5 to 14, �15 or �25; adults [age 14or older], �11 or �24)

13. Depth of breathing (infants, 6 to 8 mL/kg; adults, tidalvolume [VT] 500 mL at rest)

14. Timing ratio15. Orthopnea16. Decreased vital capacity

RELATED FACTORS22

1. Hyperventilation2. Hypoventilation syndrome3. Bone deformity4. Pain5. Chest wall deformity6. Anxiety7. Decreased energy or fatigue8. Neuromuscular dysfunction9. Musculoskeletal impairment

10. Perception or cognition impairment11. Obesity12. Spinal cord injury13. Body position14. Neurologic immaturity15. Respiratory muscle fatigue


1. Chronic obstructive or restrictive pulmonary disease2. Pneumonia3. Asthma4. Acute alcoholism (intoxication or overdose)5. Congestive heart failure6. Chest trauma7. Myasthenia gravis


Ineffective Airway ClearanceIneffective Airway Clearance means that somethingis blocking the air passage, but when air gets tothe alveoli, there is adequate gas exchange. InIneffective Breathing Pattern, the ventilatory effortis insufficient to bring in enough oxygen or to getrid of sufficient amounts of carbon dioxide. How-ever, air is able to freely move through the airpassages.

Impaired Gas ExchangeThis diagnosis indicates that enough oxygen isbrought into the respiratory system, and the carbondioxide that is produced is exhaled, but there isinsufficient exchange of oxygen and carbon dioxide at the alveolar–capillary level. There is no pro-blem with either the ventilatory effort or the airpassageways. The problem exists at the cellu-lar level.

EXPECTED OUTCOME

Will demonstrate an effective breathing pattern by [date] asevidenced by (specify criteria here, for example, normalbreath sounds, arterial blood gases within normal limits, noevidence of cyanosis).

TARGET DATES

Evaluation should be made on an hourly basis, because thisdiagnosis has the potential to be life-threatening. After thepatient has stabilized, target dates can be spaced furtherapart.


Adult Health


Perform nursing actions to maintain airway clearance.(See Ineffective Airway Clearance; enter those ordershere.)

Maintains a patent airway for gas exchange.




••••••


Adult Health


Maintain appropriate attention to relief of pain and anxi-ety via positioning and administration of medicationsas prescribed.

Raise head of bed 30 degrees or more if not contraindi-cated.

Instruct in diaphragmatic deep breathing and pursed-lipbreathing.

Reduce pain, fear, and anxiety.

Exercise caution with use of drugs that cause respiratorydepression.

Position patient in semi-Fowler’s position.

Encourage the patient’s mobility as tolerated (seeImpaired Physical Mobility).

Instruct the patient in effects of smoking, air pollution,etc., prior to discharge, on breathing pattern.

Provide teaching based on needs of the patient and familyregarding:

• Illness• Procedures and related nursing care• Implications for rest and relief of anxiety secondary to

respiratory failure• Advocacy role

Allows gravity to assist in lowering the diaphragm, andprovides greater chest expansion.

Promotes lung expansion and slightly increases pressurein the airways, allowing them to remain open longer.

These can cause altered breathing patterns (e.g., hyper-ventilation).

Promotes lung expansion.

Promotes tolerance for activities and helps with lungexpansion and ventilation.

Knowledge will assist the patient to avoid harmful envi-ronments and to protect him- or herself from theeffects from such activities.

Reduces anxiety; starts appropriate home care planning;assists the family in dealing with health-care system.

Child Health

The adult health-care plan can be implemented as developmentally appropriate with the following considerations:


Determine possible contributing factors.

Maintain appropriate emergency equipment in an accessi-ble place. (Specify actual size of endotracheal tube forthe infant, child, or adolescent, tracheotomy set size,and suctioning catheters or chest tube for size of thepatient.)

Allow at least 5 to 15 minutes per shift for the parentsand child to verbalize concerns related to illness.

Determine perception of illness by the patient and parents.

Facilitates comprehensive care planning.

Standard accountability for emergency equipment andtreatment is basic to patient care and especially sowhen risk factors are increased.

Appropriate time for venting may be hard to determine,but efforts to do so demonstrate valuing of patient andfamily needs and serve to reduce anxiety.

How the parents and child see (perceive) the patient’sproblem provides meaningful data that serve toensure sensitivity in care and provides informationregarding teaching needs. Provides cues to ques-tions regarding continued implementation oftherapeutic regimen.



••••••

Include the parents in the care of the child as appropriate,to include comfort measures, assisting with feeding,and the like.

Collaborate with appropriate health team members asneeded.

Parental involvement is critical in maintaining emotionalbonds with the child. Also augments sense of con-tributing to the child’s care, with opportunities for mas-tering the skills in a supportive environment.

Appropriate coordination of services will best meet thepatient’s needs with attention to the patient’s individ-uality.


Women’s Health


Assist the patient and significant other in identifyinglifestyle changes that may be required to preventIneffective Breathing Pattern during pregnancy (e.g.,stopping smoking or avoiding crowds during influenzaepidemics).

Develop exercise plan for cardiovascular fitness duringpregnancy.

Teach the patient to avoid wearing constrictive clothingduring pregnancy.

Teach and encourage the patient to practice correctbreathing techniques for labor.

During the latter stages of pregnancy, encourage thepatient to:

• Walk up stairs slowly.• Lie on left or right side, to get more oxygen to the fetus.• Position herself in bed with pillows for optimum com-

fort and adequate air exchange.• Take frequent rest breaks during the workday.

Carefully monitor maternal respiration during the labor-ing process.

If prolonged decrease in fetal heart tone (FHT) immedi-ately prior to delivery, administer pure oxygen (10 to12 L/min) to the mother before delivery and until ces-sation of pulsation in cord.

Evaluate and record the respiratory status of the newborninfant:

• Determine the 1-minute Apgar score.• Suction and clear mouth and pharynx with bulb syringe.• Avoid deep suctioning if possible.

Dry excess moisture off the infant with towel or blanket.

Stimulate (if necessary), using firm but gentle tactilestimulation:

• Rubbing up and down spine• Flicking heel

Increased cardiovascular fitness supports increased respi-ratory effectiveness.

Any constriction contributes to further breathing difficul-ties, and breathing becomes more difficult as theexpanding uterus and abdominal contents press againstthe diaphragm.54

Assists in preventing hyperventilation.

During this stage, the chest cavity has less room toexpand because of the enlarging uterus.55

Often edema of the latter stage of pregnancy causes“stuffy” noses and full sinuses.

Analgesics and anesthesia can cause maternal hypoxiaand reduce fetal oxygen.

Basic care measures to ensure effective respiration in thenewborn infant.

Helps stimulate the infant; prevents evaporative heat loss.




••••••

Mental Health

● N O T E : The following orders are for Ineffective Breathing Pattern Related to Anxiety.When the diagnosis is related to physiologic problems, refer to Adult Health nursing actions.



Women’s Health


Place the infant in warm environment:• Place the infant under radiant heat warmer.• Place the infant next to the mother’s skin• Cover the infant’s head with a stocking cap.• Cover both the mother and infant with a warm blanket.

Determine and record the 5-minute Apgar score.

Continue to evaluate the infant’s respiratory status and beprepared to act if necessary to resuscitate. Dependingon the infant’s response, the following nursing meas-ures can be taken:

• Administer warm, humid oxygen with face mask.• If no improvement, administer oxygen with bag and

mask.• If no improvement, be prepared for:

• Endotracheal intubation• Ventilation with positive pressure• Cardiac massage• Transport to neonatal intensive care unit

Basic protocol to care for the newborn who has respira-tory problems.

Monitor causative factors.

Place the client in a calm, supportive environment.

Maintain a calm, supportive attitude, reassuring the clientthat you will assist him or her in maintaining control.

Give the client clear, concise directions.

Have the client maintain direct eye contact with nurse.Modulate based on the client’s ability to tolerate eyecontact. Should not be done in a manner that appearsto “stare the client down.”

Instruct the client to take slow, deep breaths. Demonstratebreaths to the client, and practice with the client.Provide the client with constant, positive reinforcementfor appropriate breathing patterns.

Remain with the client until the episode is resolved.

If the client does not respond to the attempts to controlbreathing, have the client breathe into a paper bag.

Provides information on the client’s current status sointerventions can be adapted appropriately.

Anxiety is contagious, as is calm. A calm, reassuringenvironment can communicate indirectly to the clientthat the situation is safe and that the nurse can assisthim or her in mobilizing their internal resources, thusfacilitating the client’s sense of control.

Anxiety can decrease the client’s ability to focus on andunderstand a complex presentation of information.

Communicates interest in the client, and assists the clientin tuning out extraneous stimuli.

Helps stimulate relaxation response.

Reassures the client of safety and security.

Rebreathing air with higher carbon dioxide (CO2) contentslows the respiratory rate.



••••••

Distract the client from focus on breathing by beginninga deep muscle relaxation exercise that starts at theclient’s feet.

Use successful resolution of a problematic breathingepisode as an opportunity to teach the client that he orshe can gain conscious control over breathing and thatthese episodes are not out of his or her control.

Teach the client and significant others proper breathingtechniques, to include:

• Maintaining proper body alignment• Using diaphragmatic breathing (see Ineffective Airway

Clearance for information on this technique)• Use of deep muscle relaxation before the onset of inef-

fective breathing pattern begins

Practice with the client diaphragmatic breathing twice aday for 30 minutes. [Note practice times here.]

Develop a plan with the client for initiating slow, deepbreathing when an ineffective breathing pattern begins.

Identify with the client the situations that are most fre-quently associated with the development of ineffectivebreathing patterns, and assist him or her in practicingrelaxation in response to these situations 1 time a dayfor 30 minutes. [NOTE time of practice session here.]

Interrupts pattern of thought that reinforces anxietyand therefore increases breathing difficulties.

Promotes the client’s self-esteem and perceived control;also provides positive reinforcement for adaptive cop-ing behaviors.

Promotes perceived control and adaptive coping behav-iors. Provides information that will facilitate positivereinforcement from the support system, increasing theprobability for the success of the behavior change.56

Enhances relaxation response.

Early recognition of problematic situations facilitatesthe client’s ability to gain control and utilize adaptivecoping behaviors.

Positive imagery promotes positive psychophysiologicresponses and enhances self-esteem, which promotesthe possibility for a positive outcome.36


Gerontic Health


Monitor respiratory rate, depth, effort, and lung soundsevery 4 hours around the clock.

Because of age-related “air trapping,” have the patientfocus on improving expiratory effort. Instruct thepatient to inhale to the count of 1 and exhale for 3counts.57

Collaborate with occupational therapy and respiratorytherapy regarding other measures to enhance respira-tory function.

In the event of a chronic Ineffective Breathing Pattern,refer the patient to a support group such as those spon-sored by the American Lung Association.

Instruct in relaxation techniques (e.g., guided imageryor progressive muscle relaxation, to reduce stress).

Where applicable, monitor for knowledge of propermedication use, especially if inhalers are a part ofthe therapy.

Minimum database needed for this diagnosis.

Decreased alveoli and decreased elasticity lead to airtrapping, which results in hyperinflation of lungs.

Occupational therapist can teach the patient less energy-expanding means to complete activities of daily living.Respiratory therapist can assist the patient and family inlearning how to perform pulmonary toileting at home.

Provides long-term support for coping with problems;provides updated information; provides role modelingfrom other group members.

May assist in decreasing the episodes of acute breathingproblems in those with chronic Ineffective BreathingPattern.

Maximum benefit may be derived from proper drugadministration and usage. Inhalers may be difficult tooperate because of physical problems and lack ofinformation regarding proper usage.




••••••


Home Health

● N O T E : If this diagnosis is suspected when caring for a patient in the home, it isimperative that a physician referral be obtained immediately. If the patient has beenreferred to home health care by a physician, the nurse will collaborate with the physi-cian in the treatment of the patient.


Teach the client and family appropriate monitoringof signs and symptoms of Ineffective BreathingPattern:

• Cough• Sputum production• Fatigue• Respiratory status: cyanosis, dyspnea, rate• Lack of diaphragmatic breathing• Nasal flaring• Anxiety or restlessness• Impaired speech

Assist the client and family in identifying lifestylechanges that may be required in assisting to preventineffective breathing pattern:

• Stopping smoking• Prevention and early treatment of lung infections• Avoidance of known irritants and allergies• Practicing pulmonary hygiene:

• Clearing bronchial tree by controlled coughing• Decreasing viscosity of secretions via humidity and

fluid balance• Clearing postural drainage• Treatment of fear, anxiety, anger, depression, thorax

trauma, or narcotic overdoses• Adequate nutritional intake• Stress management• Adequate hydration• Breathing techniques (diaphragmatic, pursed lips)• Progressive ambulation• Pain relief• Preventing hazards of immobility• Appropriate use of oxygen (dosage, route, and safety

factors)

Teach the patient and family purposes, side effects, andproper administration techniques of medication.


Teach the family basic CPR.





Cardiac Output, Decreased 313

••••••

CARDIAC OUTPUT, DECREASED

DEFINITION22

Amount of blood pumped by the heart is inadequate to meetmetabolic demands of the body.


1. Altered heart rate and/or rhythma. Arrhythmias (tachycardia, bradycardia)b. Palpitationsc. Electrocardiographic (ECG) changes

2. Altered preloada. Jugular vein distentionb. Fatiguec. Edemad. Murmurse. Increased or decreased central venous pressure

(CVP)f. Increased or decreased pulmonary artery wedge

pressure (PAWP)g. Weight gain

3. Altered afterloada. Cold and/or clammy skinb. Shortness of breath and/or dyspneac. Prolonged capillary refilld. Decreased peripheral pulsese. Variations in blood pressure readingsf. Increased or decreased systemic vascular resistance

(SVR)g. Increased or decreased pulmonary vascular resistance

(PVR)h. Skin color change

4. Altered contractilitya. Cracklesb. Coughc. Orthopnea or paroxysmal nocturnal dyspnead. Cardiac output �4 L/mine. Cardiac index �2.5 L/minf. Decreased ejection fraction, stroke volume index

(SVI), and left ventricular stroke work index(LVSWI)

g. S3 or S4 sounds5. Behavioral and emotional factors

a. Anxietyb. Restlessness

RELATED FACTORS22

1. Altered heart rate and/or rhythm2. Altered stroke volume

a. Altered preloadb. Altered afterloadc. Altered contractility


1. Congestive heart failure2. Myocardial infarction3. Valvular heart disease4. Inflammatory heart disease (e.g., pericarditis)5. Hypertension6. Shock7. Chronic obstructive pulmonary disease (COPD)


Ineffective Tissue PerfusionDecreased Cardiac Output relates specifically to aheart malfunction, whereas Ineffective TissuePerfusion relates to deficits in the peripheral circula-tion that have cellular-level impact. Tissue perfusionproblems may develop secondary to DecreasedCardiac Output, but can also exist without cardiacoutput problems.59 In either diagnosis, close collabo-ration will be needed with medical practitioners toensure the best possible interventions for the patient.

EXPECTED OUTCOME

Will exhibit no signs or symptoms of decreased cardiac out-put by [date].

TARGET DATES

Because the nursing diagnosis Decreased Cardiac Outputis so life-threatening, progress toward meeting the expectedoutcomes should be evaluation at least daily for 3 to 5 days.If significant progress is demonstrated, then the targetdate can be increased to three-day intervals. Patientswho develop this diagnosis should be referred to a medi-cal practitioner immediately and transferred to a criticalcare unit.


Cardiac output (CO) refers to the amount of blood ejectedfrom the left ventricle into the aorta per minute. Cardiac out-put is equivalent to the stroke volume (SV), which is theamount of blood ejected from the left ventricle with eachcontraction, times the heart rate (HR), or the number ofbeats per minute:

CO � SV � HRThe average amount of cardiac output is 5.6 L per

minute. This amount varies according to the individual’samount of exercise and body size.

Cardiac output is dependent on the relationshipbetween stroke volume and the heart rate. Cardiac output ismaintained by compensatory adjustment of these two vari-ables. If the rate slows, the time for ventricular filling (dias-



••••••

or by administration of such substances as calcium andepinephrine.

Afterload is the amount of tension developed by theventricle during contraction. The amount of peripheralresistance predominantly determines the amount of tension.An excessive increase in the afterload reduces stroke volumeand cardiac output.

The heart rate is predominantly influenced by theautonomic nervous system, through both the sympatheticand parasympathetic nervous systems. The sympatheticfibers can increase both rate and force, whereas the parasym-pathetic fibers act in an opposite direction. Other factorssuch as the central nervous system pressoreceptor reflexes,cerebral cortex impulses, body temperature, electrolytes,and hormones also affect the heart rate, but the autonomicnervous system keeps the entire system in balance.58

tole) increases. This allows for an increase in the preloadand a subsequent increase in stroke volume. If the strokevolume falls, the heart rate increases to compensate.Preload, contractility, and afterload affect stroke volume.

Preload refers to the amount of stretching of themyocardial fibers. The fibers stretch as a result of theincrease in the volume of blood delivered to the ventriclesduring diastole. The degree of myocardial stretch beforecontraction is preload. Preload is determined by the venousreturn and ejection fraction (amount of blood left in the ven-tricle at the end of systole). Prolonged excessive stretchingleads to a decrease in cardiac output.

Contractility is a function of the intensity of theactinomycin linkages. Increased contractility increases ven-tricular emptying and results in increased stroke volume.Contractility can be increased by sympathetic stimulation


Adult Health


Place on cardiac monitor and continuously monitor car-diac rhythm and rate.

Collaborate with the health-care team regarding vari-ous tests including ABGs, cardiac enzymes,chemistries, echocardiograms, EKGs, and hemody-namic monitoring.

Administer oxygen, maintenance intravenous fluid(MIVF) and medications as prescribed, and monitoreffects.

Measure urinary output hourly. Measure and recordintake and total at least every 8 hours.

Weigh daily at [time] and in same weight clothing.

Provide adequate pain control.

Provide adequate rest periods:• Schedule at least one 5-minute rest after any activity.

Limit visitors and visiting time. Explain the need forrestriction to the patient and significant others. If thepresence of significant other promotes rest, allow themto stay beyond time limits.

Collaborate with dietitian regarding dietary restrictionswhen developing plan of care, and reinforce priorto discharge (e.g., sodium, fluids, calories, andcholesterol).

Collaborate with occupational therapist and the familyregarding diversional activities. Refer to:

• Physical therapist for home exercise program• Home health

Allows for assessment of contributors to decreased car-diac output.

Additional baseline data needed for accurate monitoringof condition.

Enhances myocardial perfusion and decreases workload.

Can give additional data about renal perfusion and fluidvolume balance.

Helps determine changes in fluid volume.

Decreases stress on already stressed circulatory system.

These dietary factors can compromise cardiac output.

Promotes collaboration and holistic care.



••••••

Child Health

This pattern represents a life-threatening status, which demands immediate attention.


Assess for all possible contributing factors, especiallyknown underlying cardiac anomaly.

Provide in-depth monitoring and documentation relatedto the following:

• Ventilator, if applicable:• If continuous positive airway pressure (CPAP), adjust

setting according to the physician order• Peak pressure as ordered• O2 percentage desired as ordered

• Intake and output hourly and as ordered. Notify thephysician if below 10 mL/h or as specified for size ofthe infant or child

• Excessive bleeding. If in postoperative status,notify the physician if more than 50 mL/h or asspecified.

• Tolerance of feedings• Notify the physician for:

• Premature ventricular contractions (PVCs) or otherarrhythmias

• Limits of pulse, respiratory rate, output criteria asspecified for the individual patient

• Use caution in the administration of medications asordered, especially digoxin:• Have another RN check the dose and medication

order.• Validate and document the heart rate to be greater

than the specified lower limit parameter (e.g., 100 foran infant) or as ordered per pediatric cardiologist orintensivist before administering.

• Document if the medication is withheld because ofheart rate.

• Monitor for signs and symptoms of toxicity (e.g.,vomiting).

• Ensure potassium maintenance. Collaborate with thephysician regarding frequency of serum potassiummeasurement, and immediately report results.

• Maintain digitalizing protocol.• Make sure that the parents understand the patient’s sta-

tus and treatment.• Monitor the patient’s response to suctioning, x-ray

exam, or other procedures.Ensure availability of a crash cart and emergency equip-

ment as needed, to include:• Cardiac or emergency drugs• Defibrillator• Ambu bag (pediatric or infant size)• Appropriate suctioning equipment

Provides realistic basis for plan of care.

These factors constitute the basic measures utilized inmonitoring for decompensation of cardiac status.Closely related are respiratory function, hydrationstatus, and hemodynamic status.

Standard nursing care includes availability and appropri-ate use of equipment and medications in event of car-diac arrest. Anticipation for need of equipment with achild in high-risk status is required.




••••••


Child Health


Allow time for the parents to voice concern on a regularbasis. Set aside 10 to 15 minutes per shift for thispurpose.

Encourage parental input in care, such as with feeding,positioning, and monitoring intake and output asappropriate.

Encourage the patient, as applicable, to participate in care.Allow for sensitivity to time in understanding of diagno-

sis. The seemingly abstract nature of underlying car-diac physiology, especially in noncyanotic heartdisease, can be confusing.

Support the parents in usual appropriate coping mecha-nisms.

Maintain appropriate technique in dressing change (asep-sis and cautious handwashing).

Limit visitors in immediate postoperative status asapplicable.

Help reduce patient and parental anxiety by touching andallowing the patient to be held and comforted.

Provide teaching with sensitivity to patient and parentalneeds regarding equipment, procedures, or routines(e.g., use a doll for demonstration with a toddler).

Encourage the parents to meet other parents of similarlyinvolved cardiac patients.

Address the need for the parents to continue with ADLswith confidence regarding knowledge of restrictions inthe child’s status.

Verbalization of concerns helps reduce anxiety.Attempting to set aside time for this verbalizationdemonstrates the value it holds for the patient’s care.

Parental input assists in meeting the emotional needs ofboth the parents and child, and supports the care givenby health care personnel. This action also allows forlearning essential skills in a supportive environment.

Self-care enhances sense of autonomy and empowerment.Abstract aspects of an illness often prove more difficult to

grasp. Congenital cardiac anomalies are often complexin nature, which requires health-care personnel to useconsistent terms and offer appropriate aids to depictkey issues of anatomy.

Emotional security may be afforded by encouragement ofusual coping mechanisms for age and developmentalstatus.

Standard care requires universal precautions, which mini-mize risk factors for infection.

Visitation may prove overwhelming to all when unlimitedin immediate postoperative period. Remember thatnumerous nursing–medical therapies must be attendedto during this time also.

Comforting allows the parent and child to feel moresecure and decreases feelings of intimidation the par-ents might experience from seeing numerous pieces ofequipment and activity. Human caring helps offset per-ceptions of impersonal high tech.

Individualized teaching with appropriate aids will mostlikely serve to reinforce desired learning and enlist thepatient’s cooperation.

Sharing with similarly involved clientele or familiesaffords a sense of unity, hope, and affirmation of thefuture far beyond what nurses or others may offer.

Aim should be for normalcy within parameters dictatedby the child’s condition. Strive to refrain the familyfrom labeling the child or encouraging the child tobecome a “cardiac cripple.”

Women’s Health

● N O T E : Caution the patient never to begin a new vigorous exercise plan while preg-nant. Teach the patient to exercise slowly, in moderation, and according to the individ-ual’s ability. A good rule of thumb is to use moderation and, with the consent of thephysician, continue with the pre-pregnant established exercise plan. Most professionalsdiscourage aerobics and hot tubs or spas because of the heat. It is not known at this timeif overheating by the mother is harmful to the fetus.



••••••

Assist the patient with relaxation techniques.

Assist in developing an exercise plan for cardiovas-cular fitness during pregnancy. Some good exer-cises are:

• Swimming• Walking• Bicycling• Jogging (If the patient has done this before and is

used to it, jogging is probably not harmful, but rem-ember that during pregnancy joints and muscles aremore susceptible to strain. If the patient feels pain,fatigue, or overheating, she should slow down orstop exercise.)

Refer the patient to support groups that understandthe physiology of pregnancy and have developedexercise programs based on this physiology, such asswimming classes for pregnant women at the localYWCA, childbirth education classes, or exercisevideotapes specifically directed and produced foruse during pregnancy.

Teach the patient and significant others how to avoid“supine hypotension” during pregnancy (particularlythe later stages).

Prior to the start of labor, encourage the patient to attendchildbirth education classes to learn how to work withher body during labor.

During the second stage of labor59–61:• Allow the patient to assume whatever position aids her

in the second stage of labor (i.e., upright, squatting,kneeling position, the use of birth balls, etc.).

• Provide the patient with proper physical supportduring the second stage of labor. This support mightinclude allowing the partner or support person to sitor stand beside her and support her head or shoulders,or behind her supporting her with his or her body.The partner might also stand in front of her, allowingher to lean on his or her neck. The patient may alsouse a birthing bed or chair, pillows, over-the-bedtable, or bars.

Do not urge the woman to “push, push” or to holdbreath during the second stage of labor. Allow thewoman to bear down with her contractions at herown pace:

• Encourage spontaneous bearing down only if fetal headhas not descended low enough to stimulate Ferguson’sreflex.

• Encourage the mother to push when she feels the urgeand to rest between contractions.62

Assists in stress reduction.

Assists in increasing cardiovascular fitness during preg-nancy.

The expanded uterus causes pressure on the large bloodvessels.

Avoids straining and the Valsalva maneuver.62





••••••

Mental Health


Monitor risk factors:• Medications• Past history of cardiac problems• Age• Current condition of the cardiovascular system• Weight• Exercise patterns• Nutritional patterns• Psychosocial stressors

Monitor every [number] hours (depends on level or risk,can be anywhere from 2 to 8 hours) the client’s cardiacfunctioning. [list times to observe here]:

• Vital signs• Chest sounds• Apical–radial pulse deficit• Mental status

Report alterations to the physician.

If acute situation develops, notify the physician andimplement adult health nursing actions.

If the client’s condition or other factors necessitate theclient’s remaining in the mental health area beyond theacute stage, refer to adult health nursing actions for careon an ongoing basis. This is not recommended becauseof the lack of equipment and properly trained staff tocare for this situation on most specialized care units.

Early identification and intervention helps ensure betteroutcome.

Basic database for further intervention.


Women’s Health


• Discourage prolonged maternal breath-holding (longerthan 6 to 8 seconds) during pushing.

• Assist the mother to accomplish four or more pushingefforts per contraction.

• Support the mother’s efforts in pushing, and validatethe normalcy of sensations and sounds the mother isverbalizing. (These sounds may include grunting,groaning, and exhaling during the push or breath-holding less than 6 seconds.)

Breath-holding involves the Valsalva maneuver. Increasedintrathoracic pressure due to a closed glottis causes adecrease in cardiac output and blood pressure. The fallin pressure causes a decrease in placental perfusion,causing fetal hypoxia.54,62,63

Adult Health


If the client is placed on the unit while in the rehabilita-tion stage of this diagnosis, implement the followingnursing actions: (Discuss with the client and otherhealth-care providers current rehabilitation schedule,and record special consideration here.)

Promotes the client’s perceived control and supports self-care activities.



••••••


Provide appropriate rest periods following activity.This varies according to the client’s stage in rehabil-itation. Most common times of needed rest are aftermeals and after any activity. [Note specific limitshere.]

Assist the client with implementation of exerciseprogram. List types of activity, time spent inactivity, and times of activity here. Also list specialmotivators the client may need, such as a com-panion to walk for 30 minutes three times a dayat [times].

Provide diet restrictions (e.g., low-sodium, low-calorie,low-fat, low-cholesterol, or fluid restrictions).

Monitor intake and output each shift.

Monitor for and teach the client to assess for:• Potassium loss (muscle cramps)• Chest pain• Dyspnea• Sudden weight gain• Decreased urine output• Increased fatigue

Monitor risk factors, and assist the client in developing aplan to reduce these (e.g., smoking, obesity, or stress).Refer to appropriate nursing diagnosis for assistance indeveloping interventions.

Spend 30 minutes twice a day teaching the client deepmuscle relaxation and practicing this process. [Listtimes here.]

Discuss with the patient’s support system the lifestylealterations that may be required.

Develop stress reduction program with the client, andprovide necessary environment for implementation.This could include massage therapy, meditation,aerobic exercise as tolerated, hobbies, or music.[Note specific plan here.]

Prevents excessive stress on the cardiovascular system,and prevents fatigue.

Promotes cardiovascular strength and well-being.

Decreases dietary contributions to increased risk factors.

Medications can affect fluid balance, and excessivefluid can increase demands on the cardiovascularsystem.

Increases the client’s perceived control, and promotesearly recognition and treatment of problem.

Increases the client’s perceived control, and decreasesrisk for further damage to the cardiovascular system.

Relaxation decreases stress on the cardiovascular system.

Enhances possibility for continuation of behaviorchange.56

Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized in aging clients.


Monitor the older adult for atypical signs of pain, suchas alterations in mental status, anxiety, or decreasingfunctional capacity.

Older adults may experience physiologic and psychologi-cal alterations that affect their response to pain.64




••••••

Home Health

● N O T E : If this diagnosis is suspected when caring for a client in the home, it is imper-ative that a physician referral be obtained immediately. If the client has been referred tohome health care by a physician, the nurse will collaborate with the physician in thetreatment of the client.


Teach the patient and significant others:• Risk factors (e.g., smoking, hypertension, or obesity)• Medication regimen (e.g., toxicity or effects)• Need to balance rest and activity• Monitoring of:

• Weight daily• Vital signs• Intake and output

• When to contact health-care personnel:• Chest pain• Dyspnea• Sudden weight gain• Decreased urine output• Increased fatigue

• Dietary adaptations, as necessary:• Low sodium• Low cholesterol• Caloric restriction• Soft foods



Gerontic Health


Monitor for possible side effects of diuretic therapy.

Review the health history for liver or kidney disease inpatients on diuretic therapy.

Whenever possible, give diuretics in the morning.

Teach proper medication usage (e.g., dosage, sideeffects, dangers related to missed doses, and food/druginteractions).

Teach patients who are on potassium-wasting diuretics:• The need for potassium replacement• Foods that are high in potassium (e.g., bananas)• Signs and symptoms of potassium depletion

Assist the patient and/or family to determine environmen-tal conditions that may need to be adapted to promoteenergy.

Older adults may have excessive diuresis on normaldiuretic dosage.

To avoid complications, dosages of diuretics may need tobe adjusted in those with pre-existing kidney or hepaticdisease.

Decreases problems with nocturia and consequentdistributed sleep–rest pattern or risk for injury fromfalls.

Basic safety for medication administration.

Assists in conservation of energy and balancing oxygendemands with resources.


Disuse Syndrome, Risk For 321

••••••

Assist the patient and family in identifying lifestylechanges that may be required:

• Eliminating smoking• Cardiac rehabilitation program• Stress management• Weight control• Dietary restrictions• Decreased alcohol• Relaxation techniques• Bowel regimen to avoid straining and constipation• Maintenance of fluid and electrolyte balance• Changes in role functions in the family• Concerns regarding sexual activity• Monitoring activity and responses to activity.

• Providing diversional activities when physical activityis restricted. (See Deficient Diversional Activity.)

• Pain controlTeach the family basic CPR.

Teach the client and family purposes and side effectsof medications and proper administration tech-niques.

Teach the client and family to refrain from activities thatincrease the demands on the heart (e.g., snow shovel-ing, lifting, or Valsalva maneuver).


Consult with or refer to appropriate assistive resourcesas indicated.




● N O T E : Level of damage to left ventricle should be determined before exercise pro-gram is initiated.66

DISUSE SYNDROME, RISK FOR

DEFINITION22

A state in which an individual is at risk for deterioration ofbody systems as the result of prescribed or unavoidablemusculoskeletal inactivity.


None listed.

RISK FACTORS22

1. Severe pain2. Mechanical immobilization3. Altered level of consciousness

4. Prescribed immobilization5. Paralysis

RELATED FACTORS22

The risk factors are also the related factors.


1. Cerebrovascular accident2. Fractures3. Closed head injury4. Spinal cord injury or paralysis5. Rheumatoid arthritis6. Amputation7. Cerebral palsy




••••••

well be a predisposing factor to Risk for DisuseSyndrome.

EXPECTED OUTCOME

Will exhibit no signs or symptoms of disuse syndrome by[date].

TARGET DATESDisuse syndrome can develop rapidly after the onset ofimmobilization. The initial target date, therefore, should beno more than 2 days.


Activity IntoleranceThis diagnosis implies that the individual is freely ableto move but cannot endure or adapt to the increasedenergy or oxygen demands made by the movementor activity.

Impaired Physical MobilityWith this diagnosis, the individual could moveindependently if something was not limiting themotion. Impaired Physical Mobility could very


Adult Health


According to the patient’s status, determine realisticpotential:

• Cognition• Mobility, head control, positioning• Communication, receptive and expressive, verbal or

nonverbal• Augmentive aids for daily living

Turn and anatomically position the patient. Performactive and passive ROM (range of motion) exercisesto all joints at least twice a shift while awake. [Statetimes here.]

Demonstrate and have the patient return-demonstrate iso-tonic exercises.

Arrange daily activities with appropriate regard for rest asneeded.

Maintain adequate nutrition and fluid balance on dailybasis.

Monitor the patient and family for perceived and actualhealth teaching needs, including:

• Equipment required for the patient’s care• Signs or symptoms to be reported to physician• Medication administration, instructions, and side

effects• Plans for follow-up

Refer to Impaired Physical Mobility for additional nurs-ing actions.

Improves planning and allows for setting of more realisticgoals and actual levels of functioning with regard togeneral physical condition.

Promotes circulation, prevents venous stasis, and helpsprevent thrombosis.

Helps avoid syndrome; offsets complications ofimmobility.

Provides fluid and nutrient necessary for activity.

Initiates appropriate home care planning.

Child Health


Assist the family in development of an individualizedplan of care to best meet the child’s potential.

The family is the best source for individual preferencesand needs as related to what daily living for the childinvolves.



••••••


Assist the family in identification of factors that willfacilitate progress as well as those factors that may hin-der progress in meeting the child’s potentials. Listthose factors here, and assist the family in planninghow to offset factors that hinder progress and encour-age factors that facilitate progress.

Facilitate both patient and family ventilation of feel-ings that may relate to disuse problem by schedulingof 15 to 20 minutes each nursing shift for thisactivity.

Assist the family in identification of the support systemfor best possible follow-up care.

Identifies learning needs and reduces anxiety. Fosters aplan that can be adhered to if all involved participate inits development. Empowers the family.

Ventilation of feelings assists in reducing anxiety andpromotes learning about condition.

Promotes coordination of care and cost-effective useof already available resources.

Women’s Health

This nursing diagnosis will pertain to women the same as to adults. Refer to nursing actions for Risk for ActivityIntolerance to meet the needs of women with the diagnosis of Risk for Disuse Syndrome.

Mental Health

● N O T E : The nursing actions in this section reflect the Risk for Disuse Syndromerelated to mental health, including use of restraints and seclusion. If the inactivity isrelated to a physiologic or physical problem, refer to the Adult Health nursing actions.


Attempt all other interventions before considering immo-bilizing the client. (See Risk for Violence in Chapter9 for appropriate actions.)

Carefully monitor the client for appropriate level ofrestraint necessary. Immobilize the client as littleas possible while still protecting the client andothers.

Obtain necessary medical orders to initiate methodsthat limit the client’s physical mobility.

Carefully explain to the client, in brief, concise lan-guage, reasons for initiating the intervention andwhat behavior must be present for the interventionto be terminated.

Attempt to gain the client’s voluntary compliance withthe intervention by explaining to the client what isneeded and with a “show of force” (having the neces-sary number of staff available to force compliance ifthe client does not respond to the request).

Initiate forced compliance only if there is an adequatenumber of staff to complete the action safely. (SeeRisk for Violence in Chapter 9 for a detailed descrip-tion of intervention with forced compliance.)

Promotes the client’s perceived control and self-esteem.65

Client safety is of primary importance while maintaining,as much as possible, the client’s perceived control andself-esteem.

Provides protection of the client’s rights. This shouldbe done in congruence with the state’s legal require-ments.

High levels of anxiety interfere with the client’s ability toprocess complex information. Maintains relationshipand promotes the client’s perceived control.

Communicates to the client that staff has the ability tomaintain control over the situation, and provides theclient with an opportunity to maintain perceived con-trol and self-esteem.

Staff and client safety are of primary importance.




••••••


Mental Health


Secure the environment the client will be in by removingharmful objects such as accessible light bulbs, sharpobjects, glass objects, tight clothing, metal objects,or shower curtain rods.

If the client is placed in four-point restraints, maintainone-to-one supervision.

If the client is in seclusion or in bilateral restraints,observe the client at least every 15 minutes, or morefrequently if he or she is agitated. [List observationschedule here.]

Leave a urinal in the room with the client or offer toilet-ing every hour.

Offer the client fluids every 15 minutes while he or she isawake.

Discuss with the client his or her feelings about the initia-tion of immobility, and review at least twice a day thekinds of behavior necessary to have immobility discon-tinued. [Note behaviors here.]

When checking the client, let him or her know youare checking by calling him or her by name and orient-ing him or her to day and time. Inquire about theclient’s feelings, and implement necessary realityorientation.

Provide meals at regular intervals in paper containers,providing necessary assistance. [Amount and type ofassistance required should be listed here.]

If the client is in restraints, remove restraints at leastevery 2 hours, one limb at a time. Have the client movelimbs through a full ROM and inspect for signs ofinjury. Apply lubricants such as lotion to area underrestraint to protect from injury.

Pad the area of the restraint that is next to the skin withsheepskin or other nonirritating material.

Check circulation in restrained limbs in the area belowthe restraint by observing skin color, warmth, andswelling. The restraint should not interfere withcirculation.

Change the client’s position in bed every 2 hours on[odd/even] hour. Have the client cough and deepbreathe during this time.

Place the body in proper alignment to prevent complica-tions and injury. Use pillows for support if the client’scondition allows.

If the client is in four-point restraints, place him or her onthe stomach or side or elevate the head of the bed.

Provides a safe environment by removing objects theclient could use to impulsively harm self.

Promotes client safety and communicates maintenance ofrelationship while meeting security needs.

Ensures client safety.

Meets the client’s physiologic needs and communicatesrespect for the individual.

Promotes the client’s regaining control, and clearly pro-vides the client with alternative behaviors for coping.

Promotes a sense of security, and provides informationabout the client’s mental status that will provide infor-mation for further interventions.

Meets physiologic needs while maintaining client safety.

Maintains adequate blood flow to the skin and preventsbreakdown. Maintains joint mobility and prevents con-tractures and muscle atrophy.

Protects skin from mechanical irritation from therestraint.

Early assessment and intervention prevent long-termdamage.

Protects skin from ischemic and shearing pressure dam-age. Promotes normal clearing of airway secretions.

Prevents aspiration or choking.



••••••


Place the client on intake and output monitoring to ensurethat adequate fluid balance is maintained.

Have the client in seclusion move around the room atleast every 2 hours on [odd/even] hour. During thistime, initiate active ROM and have the client coughand take deep breaths.

Administer medications as ordered for agitation.

Monitor blood pressure before administering antipsy-chotic medications.

Have the client change position slowly, especially fromlying to standing.

Assist the client with daily personal hygiene.

Have the environment cleaned on a daily basis.

Remove the client from seclusion as soon as the con-tracted behavior is observed for the required amountof time. (Both of these should be very specific andlisted here. See Risk for Violence in Chapter 9 fordetailed information on behavior change andcontracting specifics.)

Schedule a time to discuss this intervention with theclient and his or her support system. Inform thesupport system of the need for the intervention andabout special considerations related to visiting withthe client. This information must be provided withconsideration of the support system before and aftereach visit.

Promotes normal hydration, which prevents thickening ofairway secretions and thrombus formation.66

Assesses the client’s risk for the development of orthosta-tic hypotension.

The combination of immobility and antipsychotic med-ications can place the client at risk for the developmentof orthostatic hypotension. Slowing position changeallows time for blood pressure to adjust and preventsdizziness and fainting.

Gives the client a sense of control.

Communicates respect for the client.

Promotes the client’s perception of control, and providespositive reinforcement for appropriate behavior.

Promotes family understanding, and optimizes potentialfor positive client response.56

Gerontic Health



Monitor for iatrogenesis, especially in the case of institu-tionalized elderly.

Advocate for older adults to ensure that inactivity isnot based on ageist perspectives.

In the event of impaired cognitive function, remind thepatient of need for and assist the patient (or caregiver)in mobilizing efforts.

Although the regulations of the Omnibus Bill Reconcilia-tion Act (OBRA) require the least-restrictive measuresand ideally restraint-free care, older adults in long-term care may be placed at risk for disuse syndromesecondary to geri-chairs, use of wheelchairs, and lackof properly functioning or fitted adaptive equipment.In addition, there may be reluctance to prescribeoccupational therapy or physical therapy becauseof costs.

Health-care providers may be reluctant to ensure earlymobilization in older patients, especially the old-oldclientele.

Prompting may encourage increased activity anddecreased risk for disuse.




••••••


Home Health


Teach the client and family appropriate monitoring ofcauses, signs, and symptoms of Risk for DisuseSyndrome:

• Prolonged bed rest• Circulatory or respiratory problems• New activity• Fatigue• Dyspnea• Pain• Vital signs (before and after activity)• Malnutrition• Previous inactivity• Weakness• Confusion• Fracture• Paralysis


• Progressive exercise to increase endurance• ROM and flexibility exercise• Treatments for underlying conditions (cardiac,

respiratory, musculoskeletal, circulatory, neuro-logic, etc.)

• Motivation• Assistive devices as required (walkers, canes, crutches,

wheelchairs, ramps, wheelchair access, etc.)• Adequate nutrition• Adequate fluids• Stress management• Pain relief• Prevention of hazards of immobility (e.g., antiem-

bolism stockings, ROM exercises, position changes)• Changes in occupations, family, or social roles• Changes in living conditions• Economic concerns• Proper transfer techniques• Bowel and bladder regulation

Teach the client and family the purposes and side effectsof medications and proper administration techniques(e.g., anticoagulants or analgesics).

Assist the client and family to set criteria to help themdetermine when calling a physician or other interven-tions are required.

Consult with, or refer to, appropriate resources asindicated.



The locus of control shifts from the nurse to the clientand family, thus promoting self-care.

Provides additional support for the client and family, anduses already available resources in a cost-effectivemanner.


Diversional Activity, Deficient 327

••••••

DIVERSIONAL ACTIVITY, DEFICIENT

DEFINITION22

The state in which an individual experiences a decreasedstimulation from or interest or engagement in recreational orleisure activities.22


1. Usual hobbies cannot be undertaken in hospital.2. Patient’s statements regarding boredom. (Wishes there

was something to do or read, etc.)

RELATED FACTORS22

1. Environmental lack of diversional activity, as in:a. Long-term hospitalizationb. Frequent lengthy treatments


Any medical diagnosis that could be connected to the relatedfactors.


Activity IntoleranceIf the nurse observes or validates reports of thepatient’s inability to complete required tasks becauseof insufficient energy, then Activity Intolerance is theappropriate diagnosis, not Deficient DiversionalActivity.

Impaired Physical MobilityWhen the patient has difficulty with coordination,range of motion, or muscle strength and control orhas activity restrictions related to treatment, the mostappropriate diagnosis is Impaired Physical Mobility.Deficient Diversional Activity is quite likely to be acompanion diagnosis to Impaired Physical Mobility.

Social IsolationThis diagnosis should be considered if the patientdemonstrates limited contact with community, peers,and significant others. When the patient talks of lone-liness rather than boredom, Social Isolation is themost appropriate diagnosis.

Disturbed Sensory PerceptionThis diagnosis would be the best diagnosis if thepatient is unable to engage in his or her usual leisuretime activities as a result of loss or impairment of oneof the senses.

EXPECTED OUTCOME

Will assist in designing and implementing a plan to over-come deficient diversional activity by [date].

Participates in one leisure activity [number] times by[date].

Identifies resources necessary to implement actionplan by [date].

TARGET DATES

Planning and accessing resources will require a moderateamount of time. A reasonable target date would be within2 to 3 days.


Adult Health


Dialogue with the patient regarding lack of interest.

Gradually involve the patient, to the extent possible,in more daily self-care activities.

Rearrange environment as needed:• Provide ample light.• Place the bed near a window.• Schedule activities throughout the day• Provide radio, television set, DVDs, reading material,

or CDs. Ensure access.• Provide clear pathway for wheelchair, ambulations, etc.

Provide change of environment at least twice a day at[times] (e.g., out of room).

Helps the patient identify feelings and begin to deal withthem.

Increases self-worth and adequacy.

Facilitates environmental stimulation.

Creates change.




••••••

Child Health


Monitor the patient’s potential for activity or diversionaccording to:

• Attention span• Physical limitations and tolerance• Cognitive, sensory, and perceptual deficits• Preferences for gender, age, and interests• Available resources• Safety needs• Pain

Facilitate parental input in planning and implementingdesired diversional activity plan.

Allow for peer interaction when appropriate throughdiversional activity.

Consult with the play therapist and plan for introductionof play therapy here.

Provides essential database for planning desired andachievable diversion.

Helps ensure that the plan is attentive to the child’s inter-ests, thus increasing the likelihood of the child’s partic-ipation.

Involvement of peers serves to foster self-esteem andmeets developmental socialization needs.

Specialists facilitate the development of client-specificplans of care in complex situations.49


Adult Health


Encourage significant others to assist in increasing diver-sional activity by:

• Bringing books, games, or hobby materials• Visiting more frequently• Encouraging other visitors

Provide for appropriate adaptations in equipment or posi-tioning to facilitate desired diversional activity.

Provide for scheduling of diversional activity at a timewhen the patient is rested and without multiple inter-ruptions.

Consider alternate therapies (e.g., pet therapy).

Refer the patient to individual health-care practitionerswho can best assist with problem.

Reinforces “normal” lifestyle, and encourages feelingsof self-worth.

Women’s Health

● N O T E : The following refers to women placed on restrictive activities because ofthreatened abortions, premature labor, multiple pregnancy, or pregnancy-inducedhypertension.


Encourage the family and significant others to participatein the plan of care for the patient.

Promotes socialization, empowers the family, and pro-vides opportunities for teaching.


Diversional Activity, Deficient 329

••••••


Encourage the patient to list lifestyle adjustments thatneed to be made as well as ways to accomplish theseadjustments.

Teach the patient relaxation skills and coping mecha-nisms.

Maintain proper body alignment with use of positioningand pillows.

Provide diversional activities:• Hobbies (e.g., needlework, reading, painting, or

television)• Job-related activities as tolerated (that can be

done in bed) (e.g., reading, writing, or telephoneconferences)

• Activities with children (e.g., reading to the child,painting or coloring with the child, allowing the childto “help” the mother such as bringing water to themother or assisting in fixing meals for mother)

• Encourage help and visits from friends and relatives(e.g., visit in person, telephone visit, help with child-care, or help with housework).

Basic problem-solving technique that encourages thepatient to participate in his or her care. Will increaseunderstanding of the current condition.

Provides a variety of options to offset deficit.

Mental Health


Determine the source of deficient diversional activity.Is the nursing unit appropriately stimulating for thelevel or type of clients, or is the problem the client’sperceptions?

Nursing Unit–Related ProblemsDevelop a milieu therapy program:

• Include seasonal activities for clients, such as parties,special meals, outings, or games. Post schedule ofactivities in client care areas. Enlist clients in activityplanning.

• Alter the unit environment by changing pictures,adding appropriate seasonal decorations, updating bul-letin boards, and cleaning and updating furniture.

• Alter the mood of the unit with bright colors, seasonalflowers, or appropriate music.

• Develop group activities for clients, such as teamsports; Ping-Pong; bingo games; and activity planning,meal planning, meal preparation, current events discus-sion, book discussion, exercise, or craft groups.

• Decrease emphasis on television as a primary unitactivity.

• Provide books, newspapers, records, tapes, and craftmaterials.

Recognizes the impact of physical space on the client’smood.

Promotes here-and-now orientation and interpersonalinteractions.

Role models for clients skills in developing and initiatingdiversional activities.

Enhances the aesthetics of the environment and has apositive effect on the client’s mood.35

Colors and sounds affect the client’s mood.33

Provides opportunities to build social skills, explore dif-ferent types of activities, and learn alternative methodsof coping.

Television does not provide opportunities for learningalternative coping skills and decreases physicalactivity.

These resources assist the client in meeting belongingneeds by facilitating interaction with others on the unitand the world around him or her.




••••••


Mental Health


• Use community service organizations to provideprograms for clients.

Collaborate with the occupational therapist for ideasregarding activities and supplies. Note schedule forthese activities here.

Collaborate with the physical therapist regarding physicalexercise program.

Client Perception–Related ProblemsDiscuss with the client past activities, reviewing those

that have been enjoyed and those that have been triedand not enjoyed.

List activities that the client has enjoyed in the past, withinformation about what keeps the client from doingthem at this time.

Monitor the client’s energy level, and develop an activ-ity that corresponds to the client’s energy level andphysiologic needs. For example, a manic clientmay be bored with playing cards, and yet physio-logic needs require less physical activity than theclient may desire, so an appropriate activity wouldaddress both these needs. [Note client’s activityplan here.]

Develop with the client a plan for reinitiating a previ-ously enjoyed activity. [Note that plan here.]

Develop time in the daily schedule for that activity.[Note that time here.]

Relate activity to enjoyable time, such as a time for inter-action with the nurse alone or interaction with otherclients in a group area.

Provide positive verbal feedback to the client about his orher efforts at the activity.

Assist the client in obtaining necessary items to imple-ment activity, and list necessary items here.

Develop a plan with the client to attempt one newactivity—one that has been interesting for him orher but that he or she has not had time or direction topursue.[Note plan and rewards for accomplishing goals here.]

Have the client set realistic goals for activity involve-ment (e.g., one cannot paint like a professional in thebeginning).

Discuss feelings of frustration, anger, and discom-fort that may occur as the client attempts a newactivity.

Frame mistakes as positive tools of learning newbehavior.

Provides varied sensory stimulation.

Promotes the client’s sense of control.

Promotes development of alternative coping behaviors byassisting the client in choosing appropriate activities.


Interaction can provide positive reinforcement for engag-ing in the activity.

Positive verbal reinforcement encourages appropriatecoping behaviors.

Facilitates appropriate coping behaviors.

Promotes the client’s perceived control, and provides pos-itive reinforcement for the behavior.

Promotes the client’s strengths and self-esteem.

Verbalization of feelings and thoughts provides opportu-nities for developing alternative coping strategies.

Promotes the client’s strengths.


Dysfunctional Ventilatory Weaning Response (DVWR) 331

••••••

Gerontic Health

In addition to the interventions for Adult Health, the following can be utilized for the aging client.


Assess the client’s level of activity prior to illness/hospi-talization.

Provide at least 10 to 15 minutes per shift, while thepatient is awake, to engage in reminiscing with thepatient.

Establishes a baseline and allows for realistic goal settingand intervention.

Increases self-esteem, and focuses on strengths thepatient has developed over his or her lifetime.67

Home Health


Monitor factors contributing to deficient diversionalactivity.

Involve the client and family in planning, implement-ing, and promoting an increase in diversionalactivity via:


Assist the client and family in lifestyle adjustments thatmay be required:

• Time management• Work, family, social, and personal goals and priorities• Rehabilitation• Learning new skills or games• Development of support systems• Stress management techniques• Drug and alcohol use issues

Refer the patient to appropriate assistive resourcesas indicated.

Provides database for prevention and/or earlyintervention.

Involvement improves motivation and improves the out-come.



c. Slight increased respiratory rate from baselined. Queries about possible machine malfunctione. Expressed feelings of increased need for oxygenf. Fatigueg. Increased concentration on breathingh. Breathing discomfort

2. Moderate DVWRa. Slight increase from baseline blood pressure

�20 mm Hgb. Baseline increase in respiratory rate �5 breaths per

minutec. Slight increase from baseline heart rate �20 beats

per minute

DYSFUNCTIONAL VENTILATORYWEANING RESPONSE (DVWR)

DEFINITION22

A state in which a patient cannot adjust to lowered levels ofmechanical ventilator support, which interrupts and pro-longs the weaning response.21


1. Mild DVWRa. Warmthb. Restlessness



••••••

ative events in the room, low nurse–patient ratio,extended nurse absence from bedside, or unfamiliarnursing staff)

c. History of multiple unsuccessful weaning attemptsd. History of ventilator dependence �1 weeke. Inappropriate pacing of diminished ventilator supportf. Inadequate social support


1. Closed head injury2. Coronary bypass3. Respiratory arrest4. Cardiac arrest5. Cardiac transplant


Ineffective Breathing PatternIn this diagnosis, the patient’s respiratory effort isinsufficient to maintain the cellular oxygen supply.This diagnosis would contribute to the patient’s beingplaced on ventilatory assistance; however, DVWRoccurs after the patient has been placed on a ventila-tor and efforts are being made to re-establish a regu-lar respiratory pattern. The key difference is whetheror not a ventilator has been involved in the patient’stherapy.

Impaired Gas ExchangeThis diagnosis refers to the exchange of oxygen andcarbon dioxide in the lungs or at the cellular level.This probably has been a problem for the patient andis one of the reasons the patient was placed on a ven-tilator. DVWR would develop after the patient hasreceived treatment for the impaired gas exchange viathe use of a ventilator.

EXPECTED OUTCOME

Will be weaned from the ventilator by [date]. Patient willdemonstrate progressively longer intervals off ventilator[target intervals in terms of hours]

Will maintain

TARGET DATES

Initial target dates should be in terms of hours as the patientis going through the weaning process. As the patientimproves, the target date could be expressed in increasingintervals from 1 to 3 days.

d. Pale, slight cyanosise. Slight respiratory accessory muscle usef. Inability to respond to coachingg. Inability to cooperateh. Apprehensioni. Color changesj. Decreased air entry on auscultationk. Diaphoresisl. Eye widening, “wide-eyed look”m. Hypervigilence to activities

3. Severe DVWRa. Deterioration in arterial blood gases from current

baselineb. Respiratory rate increases significantly from baselinec. Increase from baseline blood pressure �20 mm Hgd. Agitatione. Increase from baseline heart rate �20 beats per

minutef. Paradoxical abdominal breathingg. Adventitious breath soundsh. Cyanosisi. Decreased level of consciousnessj. Full respiratory accessory muscle usek. Shallow, gasping breathsl. Profuse diaphoresism. Discoordinated breathing with the ventilatorn. Audible airway secretion

RELATED FACTORS22

1. Physiologica. Inadequate nutritionb. Sleep pattern disturbancec. Uncontrolled pain or discomfortd. Ineffective airway clearance

2. Psychologicala. Patient-perceived inefficacy about the ability to weanb. Powerlessnessc. Anxiety (moderate or severe)d. Knowledge deficit of the weaning process and patient

rolee. Hopelessnessf. Fearg. Decreased motivationh. Decreased self-esteemi. Insufficient trust of the nurse

3. Situationala. Uncontrolled episodic energy demands or problemsb. Adverse environment (noisy, active environment, neg-



••••••


Adult Health


Collaborate with the health-care team to devise a planfor ventilatory weaning and explain the weaningprocedure.

Initiate supportive measures:• Ensure that nutrient intake supports energy require-

ments for spontaneous breathing.• Provide ample rest periods.

• Initiate measures to minimize bronchial secretions. Seenursing actions for Ineffective Airway Clearance.

Limit activity prior to removing the patient off theventilator.

Limit use of medications that cause respiratorydepression.

Monitor for signs and symptoms of inability to tolerateweaning process, including abdominal breathing,increased respiratory effort, decreasing oxygen satura-tion, tachycardia, and tachypnea. Stop the weaningprocess before the patient becomes exhausted.

Gradually increase times off the ventilator as tolerated.

Allow the patient to rest overnight on the ventilator.

Document times and length of time the patient is able tostay off the ventilator.

If the patient is unable to wean while still in the hospital,initiate referral to pulmonary rehabilitation program assoon as feasible.

Psychologically prepares patient for weaning process.

Ensures patient has adequate energy stores to assumework of breathing.

Interference with gas exchange will adversely affect theweaning process.

Nursing activity and/or visitors can increase patientenergy expenditure, leaving less energy for ventilatoryweaning.

Essential monitoring for efficacy of the weaning process.

Allows for periods of rest.

Essential for monitoring progress.

Coordinates team efforts and allows sufficient planningtime for home care.

Child Health


Monitor for contributing factors68:• Pathophysiologic health concerns (e.g., infections, ane-

mia, fever, or pain)• Previous respiratory history, especially risk indicators of

reactive airway disease and bronchopulmonary dysplasia• Previous cardiovascular history, especially risk indica-

tors such as increased or decreased pulmonary bloodflow associated with congenital deficits

• Previous neurologic status• Recent surgical procedures• Current medication regimen• Psychological and emotional stability of the parents as

well as the child

Provides a database that will assist in generating the mostindividualized plan of care.




••••••


Child Health


Collaborate with the physician, respiratory therapist, andother health-care team members to determine respira-tory parameters that suggest readiness to begin theweaning process69:

• Spontaneous respirations for age (e.g., rate or depth)• Oxygen saturations in normal range for condition (e.g.,

spontaneous tidal volume of 5 mL/kg body weight,vital capacity per Wright) Respirometer of 10 mL/kgbody weight, effective oxygenation with positive end-expiratory pressure (PEEP) of 4 to 6 centimeters ofH2O. An exception to the norms would exist if theinfant has transposition of the great vessels.

• Blood gases in normal range• Stable vital signs• Parental or patient anxiety regarding respirator• Patient’s facial expression and ability to rest• Resolution of the precipitating cause for intubation and

mechanical support• Tolerance of suctioning and use of Ambu bag• Central nervous system and cardiovascular stability• Nutritional status, muscle strength, pain, drug-induced

respiratory expression, or sleep deprivation

Specific ventilator-related criteria offer the best decision-making support for determining the best plan ofventilator weaning.

● N O T E : Oxygen saturation, blood gases, and vital signs may be abnormal secondaryto chronic lung damage with accompanying hypoxemia and hypercapnia, but the pHmay be normal with metabolic compensation for chronic respiratory acidosis. In thisinstance, acceptable ranges would be defined.Provide constant one-to-one attention to the patient, and

focus primarily on cardiorespiratory needs. HaveCPR backup equipment readily available.

Monitor the anxiety levels of the patient and familyat least once per shift.

Monitor patient-specific parameters during actualattempts at weaning:

• Arterial blood gases• Vital signs• Chest sounds• Pulse oximetry• Chest X-ray exam• Hematocrit

Provide teaching as appropriate for the patient and fam-ily, with emphasis on the often slow pace of weaning.

Hierarchy of needs for oxygenation must be met for allvital functions to be effective in homeostasis.Anticipatory safety for a patient on a ventilatordemands backup equipment in case of failure of thecurrent equipment.

Expression of feelings will assist in monitoring familyconcerns and help reduce anxiety.

Assists in further planning for weaning.

Assessment and individualized learning needs allowappropriate focus on the patient. Explanation regard-ing the slow pace encourages a feeling of successrather than failure when each session does not meetthe same time limits as the previous session.



••••••


Provide attention to rising related emotional problemssecondary to the association of ventilators with termi-nal life support.

Refer the patient for long-term follow-up as needed.

Administer medications as ordered with appropriateattention to preparation for weaning (e.g., careful useof paralytic agents or narcotics).

Maintain a neutral thermal environment.

Provide the parents the option to participate in careas permitted.

Communicate with the infant or child using age-appropri-ate methods (e.g., an infant will enjoy soft music or afamiliar voice, whereas an older child may be able touse a small magic slate or point to key terms).

With the need to implement intubation and ventilation,there can arise a myriad of concerns regarding thepatient’s prognosis.

Fosters long-term support and coping with care at home.

The best chance for successful weaning includes appro-priate consciousness, no respiratory depression, andadequate neuromuscular strength. Special caution mustbe taken in positioning the patient receiving neuromus-cular blocking agents so that dislocation of joints doesnot occur.70

Altered oxygenation and metabolic needs occur ininstances of hyperthermia and hypothermia.

Family input offers emotional input and security for thechild in times of great stress, thereby allowing forgrowth in parental–child coping behaviors.

Effective communication serves to allow for expressionof or reception of messages of cares or concerns,thereby acknowledging the value of the patient.

Women’s Health

The nursing actions for Women’s Health clients with this diagnosis are the same as those for Adult Health.

Mental Health

This diagnosis is not appropriate for the mental health care unit.

Gerontic Health



Monitor the patient for presence of factors that makeweaning difficult, such as71:

• Poor nutritional status• Infection• Sleep disturbances• Pain• Poor positioning• Large amounts of secretions• Bowel problems

Ensure that communication efforts are enhanced by theproper use of sensory aids such as eyeglasses, hearingaids, or adequate light, decreased noise level in room,speaking in a low-pitched tone of voice, and facing thepatient when speaking. If written instructions are used,make sure they are brief, jargon-free, printed or writtenin dark ink, and printed or written in large letters.

These factors can significantly contribute to a delay in theweaning process.

Effective communication is critical to the success ofweaning efforts. Lack of information or misinterpretedinformation may result in increased anxiety anddecreased weaning success.




••••••


Gerontic Health


Maintain same staff assignments whenever possible.72

Contract with the patient for short-term and long-termweaning goals, providing reinforcements and rewardsfor progress. Use wall chart or diary to record progress.

Facilitates communication, and decreases anxiety andfear caused by unfamiliarity with caregivers.

Home Health

Clients are discharged to the home health setting with ventilators; however, the nursing care required is the same as thoseactions covered in Adult Health and Gerontic Health.

FALLS, RISK FOR

DEFINITION22

Increased susceptibility to falling that may cause physicalharm.


1. Adultsa. Demographics

(1) History of falls(2) Wheelchair use(3) Age 65 or older(4) Female (if elderly)(5) Lives alone(6) Lower limb prosthesis(7) Use of assistive devices

b. Physiologic(1) Presence of acute illness(2) Postoperative conditions(3) Visual difficulties(4) Hearing difficulties(5) Arthritis(6) Orthostatic hypotension(7) Sleeplessness(8) Faintness when turning or extending neck(9) Anemias

(10) Vascular disease(11) Neoplasms (i.e., fatigue or limited mobility)(12) Urgency and/or incontinence(13) Diarrhea(14) Decreased lower extremity strength(15) Postprandial blood sugar changes(16) Foot problems

(17) Impaired physical mobility(18) Impaired balance(19) Difficulty with gait(20) Unilateral neglect(21) Proprioceptive deficits(22) Neuropathy

c. Cognitive(1) Diminished mental status (e.g., confusion, delir-

ium, dementia, impaired reality testing)d. Medications

(1) Antihypertensive agents(2) Angiotensin-converting enzyme (ACE) inhibitors(3) Diuretics(4) Tricyclic antidepressants(5) Alcohol use(6) Antianxiety agents(7) Hypnotics or tranquilizers(8) Narcotics

e. Environment(1) Restraints(2) Weather conditions (e.g., wet floors or ice)(3) Throw or scatter rugs(4) Cluttered environment(5) Unfamiliar, dimly lit rooms(6) No antislip material in bath and/or shower

2. Childrena. Younger than 2 years of ageb. Male gender when younger than 1 year of agec. Lack of autorestraintsd. Lack of gate on stairse. Lack of window guardf. Bed located near windowg. Unattended infant on bed, changing table, or sofah. Lack of parental supervision


Falls, Risk For 337

••••••

RELATED FACTORS22

The risk factors also serve as related factors.


1. Vertigo2. Osteoporosis3. Hypotension4. Recent history of anesthesia5. Cataracts or glaucoma6. Cerebrovascular insufficiency7. Epilepsy


Risk for InjuryThis diagnosis is a broader diagnosis than Risk forFalls. Certainly, a fall would increase the likelihood of

injury, but making the specific diagnosis of Risk forFalls as a primary problem allows more specific focuson prevention.

Impaired Physical MobilityThis diagnosis is a contributing factor to falls.Again, Risk for Falls would be a more specificdiagnosis.

EXPECTED OUTCOME

Will have experienced no falls by [date].

TARGET DATES

A patient with this diagnosis would need to be checkedat least hourly. After some of the risk factors have been alle-viated, an appropriate target date would be 5 days.


Adult Health

● N O T E : Assessment of risk factors for falls is an important element in prevention offalls. Risk factors associated with falls include a history of falls, fear of falling, boweland bladder incontinence, cognitive impairment, dizziness, functional impairment, med-ications, medical problems, and environmental risks. Hospitalization or illness of theotherwise healthy adult often results in increased risk for falls. Chronically ill adultsoften experience these risk factors.73


Keep the bed in the lowest position.

Remove hazards from the environment.

Place the patient in a room close to the nurses’ station.

Assess nutrition and elimination needs at least every2 hours.

Exercise caution with medications including sedatives,hypnotics, narcotics, or diuretics.

Keep frequently used items within reach.

Provide slip-resistant surfaces in the bathroom tub orshower; raise toilet seats.

Ensure that there are grab bars in bathroom or in theroom; ensure that handrails are installed in halls.

Involve the patient in identifying ways to prevent falls.

Use protective alarm sensors as necessary.

Use alternatives to physical or chemical restraints, includ-ing continuous caretaker.

Educate the family on fall prevention strategies.

Refer to the Gerontic and Home Health NursingCare Plans.

Lessens the distance of a fall.

Safety and security.

Allows for close visualization of patient.

May precipitate disorientation or contribute todisequilibrium.

Avoids reaching and becoming off balance.74

Empowers the patient to take an active role in his or herown health care.

Identifies when the patient is outside safety limits.74

Lessens independence and may lead to more falls.75

Empowers the family to become a part of caregiving.




••••••


Child Health


Identify all contributing factors, including:• Neurologic• Musculoskeletal• Cardiovascular• Cognitive• Developmental• Environmental• Situational• Pharmacologic• Medical

Ensure safety in the environment on an ongoing basis.

Provide teaching to the client, family, and health teammembers based on specific content per plan.

Provide transfer of principles of prevention to alternatesettings as required per daily activities of living (e.g.,playroom, dining area, etc.).

Maintain ongoing surveillance for potential changes.

Determine the need for post-hospitalization teachingregarding preventive or related data.

Administer medications, treatments, or related care in amanner that permits the best likelihood for noninterfer-ence in usual mobility.

Ensure adequate lighting on a 24-hour basis.

Ensure availability of assistive devices as required perclient (e.g., corrective lenses, braces, helmet, etc.).

A holistic approach provides a thorough database to pro-vide individualized care.

Risk is reduced by anticipatory safety measures.

Standardization and shared plan will afford the bestchance for attainment of goal with empowerment ofothers to provide appropriate assistance.

Offers validation of the importance of principles of safetythat can be applied in the future as needed.

Constant anticipatory safety needs are mandatory.

Provides appropriate time for questions or concerns priorto dismissal.

Clustering of care and appropriate attention to timing ofmedications or treatments will best afford safety andlessen risk.

Safety needs include appropriate lighting, especially atnight or in times of darkness.

Appropriate augmentation as needed will prevent likeli-hood of falls.

Women’s Health

The nursing interventions for this diagnosis in Women’s Health are the same as those for Adult Health and GeronticHealth.

Mental Health

The nursing interventions for this diagnosis in Mental Health are the same as those for Adult Health and Gerontic Health.

Gerontic Health

● N O T E : Aging adults are at high risk for falls due to the prevalence of common fallrisk factors among this age group. Common risk factors for falls include muscle weak-ness, history of falls, gait or balance deficits, use of assistive devices, visual deficits,arthritis, impaired activities of daily living, depression, cognitive impairment, and ageolder than 80 years. (National Guidelines Clearinghouse, http://www.guidelines.gov)


Falls, Risk For 339

••••••


Perform fall risk assessment on all older clients, appropri-ate to the caregiving site.

All older persons should be asked at least once a yearabout falls.

All older persons who report a single fall should beobserved as they stand up from a chair withoutusing their arms, walk several paces, and return(Get Up and Go Test). Those demonstrating nodifficulty or unsteadiness need no further assessment.Persons with difficulty or demonstrated unsteadinessperforming this test require further assessment.(National Guidelines Clearinghouse, http://www.guidelines.gov)

Older persons who have recurrent falls or risk for fallsshould be offered long-term exercise and balance train-ing. (National Guideline Clearinghouse,http://www.guidelines.gov)

Persons who have fallen should have their medicationsreviewed and altered or stopped as appropriate.Particular attention should be given to persons takingfour or more medications and those taking psy-chotropic medications. (National GuidelinesClearinghouse, http://www.guidelines.gov)

Instruct client to use assistive devices as a part of a com-prehensive program for falls prevention.73

Carefully monitor the client’s cardiovascular status andaddress issues such as syncope and dysrhythmias.73

Carefully assess the client’s visual system and collaboratewith the health-care team to address any remediablevisual abnormalities.73

Avoid the use of restraints as a falls prevention method.

Ensure that any sensory adaptive equipment is availableand properly functioning. [Note equipment needed forclient here.]

Consult with occupational therapist and physical therapistfor balance, gait, transfer, and strength assessment andtraining as needed.

Review drug list to evaluate any medication-associatedrisks, such as diuretics, antihypertensives, sedatives,psychotropics, and hypoglycemic drugs.

Develop a teaching plan for the client and/or caregiver toreduce fall potential based on risk factors present.

Risk factors for falls in older clients are multifactorialand site-specific assessment tools help target factors(such as equipment, structures, furnishings, personnelissues) that may increase fall potential.

Promotes strength and balance needed to prevent falls.

Removes a potential risk factor for future falls.

Assistive devices alone are not adequate to prevent falls.

Falls that have a cardiac cause may be amenable to treat-ment of the cardiac condition (pacing, medicationchanges).

Visual changes are associated with a higher rate of falls.

The use of restraints has not been demonstrated toprevent falls and may contribute to clientinjury.73

Visual and auditory deficits can affect balance.14

The factors listed have been identified as having animpact on the potential for falls in older adults.19

These medications have been shown to increase theincidence of falls in older adults.76

Raises awareness of fall potential and strategies needed toreduce risks.




••••••




Assess the home for hazards:• Throw rugs• Electrical cords• Uneven floor surfaces• Raised thresholds• Slick floors• Animals

Modify the home to reduce or eliminate hazards:• Skid-proof surfaces in showers and on stairs.• Mark uneven areas and stairs.• Eliminate throw rugs and cords.• Install safety rails in halls, stairs, and bathrooms.

Assess client-related factors that increase risk for falls:• Poorly fitting shoes• Medications that increase sedation or contribute to

dizziness• History of falls• Inner ear infections or disorders

Educate the client and family about reducing client-related factors that increase the risk for falls:

• Medication effects or side effects• Changing position slowly to reduce risk• Acquire properly fitting, nonskid footwear

Utilize night lights in dark areas.Reduce or eliminate clutter in traffic areas.Refer the client and family to an emergency response

service as appropriate.Utilize gates to keep pets isolated if they pose a risk

for falls.Request a physical therapy consult as appropriate to

improve muscle strength and gait.Request a physical therapy consult to ensure the correct

use of assistive devices.


The items listed are primary hazards.


To provide rapid response should a fall occur.

To prevent injury before it occurs.

FATIGUE

DEFINITION

An overwhelming sustained sense of exhaustion anddecreased capacity for physical and mental work at usuallevel.22


1. Inability to restore energy even after sleep2. Lack of energy or inability to maintain usual level of

physical activity3. Increase in rest requirements

4. Tired5. Inability to maintain usual routines6. Verbalization of an unremitting and overwhelming lack

of energy7. Lethargic or listless8. Perceived need for additional energy to accomplish

routine tasks9. Increase in physical complaints

10. Compromised concentration11. Disinterest in surroundings, introspection12. Decreased performance13. Compromised libido


Fatigue 341

••••••

4. Menopause5. Depression6. Anemia


Disturbed Sleep PatternFatigue is defined as a sense of exhaustion anddecreased capacity for mental work regardless ofadequate sleep. In this sense, Fatigue may be consid-ered an alteration in quality, not quantity, of sleep, andis subjective.

Decreased Cardiac OutputDecreased oxygenation to the muscles, brain, and soon could result in a sense of fatigue.

Imbalanced Nutrition, LessThan Body RequirementsDecreased nutrition will ultimately lead to decreasedmuscle mass and decreased energy, which will resultin Fatigue.

EXPECTED OUTCOME

Will have decreased complaints of fatigue by [date].Will resume performance of normal routine for [num-

ber] minutes/hours by [date].

TARGET DATES

Fatigue can have far-reaching impact. For this reason, theinitial target date should be set at no more than 4 days.


Adult Health


Collaborate with the diet therapist for in-depth dietaryassessment and planning. Monitor the patient’s foodand fluid intake daily.

Identify contributory factors on a daily basis at [time].

Carefully plan activities of daily living (ADLs) anddaily exercise schedules with input from the patient.Determine how to best foster future patterns that willmaintain optimal sleep–rest patterns.

Adequate, balanced nutrition assists in reducing fatigue.

Assists in identifying causative factors, which then can betreated.

Realistic schedules based on the patient’s input promoteparticipation in activities and a sense of success.


14. Drowsy15. Feelings of guilt for not keeping up with responsi-

bilities

RELATED FACTORS22

1. Psychologicala. Boring lifestyleb. Stressc. Anxietyd. Depression

2. Environmentala. Humidityb. Lightsc. Noised. Temperature

3. Situationala. Negative life eventsb. Occupation

4. Physiologica. Sleep deprivationb. Pregnancyc. Poor physical conditiond. Disease statese. Increased physical exertionf. Malnutritiong. Anemia


1. Acquired immunodeficiency syndrome (AIDS)2. Hyper- or hypothyroidism3. Cancer



••••••


Adult Health


Instruct the patient in stress reduction techniques. Havethe patient return-demonstrate at least once a daythrough the day of discharge.

Provide frequent rest periods. Schedule at least 30 min-utes of rest after any strenuous activity.

Assist the patient with self-care as needed. Plan gradualincrease in activities over several days.

Promote rest at night:• Warm bath at bedtime• Warm milk at bedtime• Back massage

Avoid sensory overload or sensory deprivation. Providediversional activities.

Limit visitation as necessary.

Address issues that will interfere with sleep, includingpain.

Educate the patient to avoid activities that willinterfere with sleep or reduce quality of sleep(consumption of alcohol or stimulants, or exercisingclose to bedtime).

Refer to local exercise center for assistance with regularexercise plan.

Mental and physical stress contribute greatly to a sense offatigue.

Allows the patient to gradually increase strength and tol-erance for activities.

Sensory stimulation can deplete energy stores; diversionalactivities help prevent overload or deprivation byfocusing the patient’s concentration on an activity he orshe personally enjoys.

Regular exercise decreases fatigue.

Child Health


Develop, with patient and parents, a plan to best addresscontributory factors as determined by verbalized per-ceptions of fatigue (may be related to parents’ percep-tions). [Note plan here.]

Provide daily feedback and positive reinforcementregarding progress, and reassess the child’s and thefamily’s perception of fatigue. [Note those thingsthat are reinforcing to the child here.]

Ensure safety needs according to the child or infant’s ageand developmental capacity.

Collaborate with other members of the health-care teamas indicated, especially pediatrician, pediatric cardiolo-gist, dietician, and physical therapist.

Parents are best able to describe objective behaviors thatoffer cues to fatigue factors, especially when thepatient cannot speak or describe his or her feelings.When the plan is developed in collaboration withthe client and family there is a greater probabilityof success.49

Because of the ever-changing fatigue factors, close atten-tion to progress will aid in a sense of mastery andobjectify concerns.

Standard accountability is to provide for safety needswith special attention to the child’s age, developmentalcapacity, parental education, compliance, etc.

Offers input from team members to safeguard the client’sprogress.


Fatigue 343

••••••

Women’s Health


During pregnancy, schedule rest periods during theday.

Find restful area, and get away from the work area torest 5 to 10 minutes with feet propped above theabdomen, once in the morning and once in theafternoon.

During lunch, leave the work area to rest 10 to 15 min-utes lying on the left side or with feet propped abovethe abdomen.

Have the patient research the possibility of split time orjob sharing at work during pregnancy.

Teach the patient relaxation techniques.

Teach the patient to use music of preference during restperiods.

Plan for at least 6 to 8 hours of sleep during the night.(See Disturbed Sleep Pattern, Chapter 6, for nursingactions to promote sleep.)

Involve significant others in discussion and problem-solving activities regarding lifestyle changes neededto reduce fatigue.

After delivery, identify a support system that can assistthe patient with infant care and household duties.

Learn to rest and sleep when the infant sleeps.

Plan daily activities to alleviate unnecessary steps and toallow for frequent rest periods.

• If bottle-feeding, prepare formula for 24 hours at atime.

• If breastfeeding, let spouse get up at night and bringthe baby to the mother.

• If breastfeeding, sleep with the baby in bed.

• Prepare extra when cooking meals for the family, andfreeze extra for future meals (e.g., prepare big batch ofstew or spaghetti on one day, and freeze portions forfuture meals).

Plan return to work on a gradual basis (e.g., work part-time for the first 2 weeks, gradually increasing time atwork until full-time by end of 4 weeks).

Realistic planning to offer brief rest periods during theday.

Techniques induce a restful state and can be used forshort periods of rest as well as more extended periodsof rest.

Assists with relaxation.

The family can assume more responsibilities to assist inincreasing rest time for the patient.

Assists in alleviating fatigue related to trying to managehousehold as always as well as trying to care for a newbaby.

Conserves energy and increases amount of time availablefor rest.

The baby begins to feed for longer periods and begins tosleep longer more quickly. Both the mother and infantget more rest.

Provides gradual return to activities, and decreases likeli-hood of fatigue.




••••••


Mental Health

● N O T E : All goals established for the nursing actions should be achievableand adjusted as the client’s condition changes.


Schedule time by which the client must be out of bedand dressed. [Note time here.] Initially this goal maybe limited to the client getting out of bed withoutdressing.

Assist the client with grooming activities. [Note here thedegree of assistance needed as well as any specialitems needed.]

While assisting the client with grooming activities, teachperformance of tasks in energy-efficient ways (e.g.,placing all necessary items in one place before groom-ing is begun).

Provide the client with appropriate rewards for accom-plishing established goals (Note special goals here withthe reward for achievement of goal). Establish rewardswith client input.

Establish time for the client to rest during the day.Initially this will be more frequent and diminish as theclient’s condition changes. [Note times and duration ofrest periods here.]

Walk with the client on unit [number] minutes [number]times a day.

Have the client identify pleasurable activities that cannotbe performed because of fatigue.

Identify one pleasurable activity, and develop a graduallyescalating plan for client involvement in this activity.Provide rewards for accomplishment of each step inthis plan.

Provide the client with foods that are high in nutritionalvalue and are easy to consume.

Talk with the client 30 minutes twice a day. Topics forthis discussion should include:

• Client’s perception of the problem• Identification of thoughts that support the feeling of

fatigue• Identification of thoughts that decrease feelings of

fatigue• Identification of unrealistic goals• Client’s evaluation of and attitudes toward self

Provides goal the client can achieve, and enhances self-esteem.

Promotes the client’s sense of control, and enhances self-esteem.

Promotes the client’s control by providing increasedopportunity for self-care.

Positive reinforcement encourages appropriate behavior.

Meets physiologic need for rest. Also provides the clientwith an opportunity for perceived control in determin-ing when these rest periods should be provided.

Promotes cardiorespiratory fitness, and promotes self-esteem by providing a goal the client can meet.Interaction with the nurse can provide positive rein-forcement for this activity.

Promotes positive orientation by connecting the clientwith images of past pleasures, and provides materialfor developing positive imaging.

Promotes positive orientation by providing the client withpositive goal to work toward. This will increase moti-vation. Positive reinforcement encourages behavior.

Meets physiologic needs for nutrition in a manner thatconserves energy.

Promotes the client’s sense of control by providing timefor his or her input into the plan of care on a dailybasis; also provides positive reinforcement throughsocial interaction with the nurse and verbal feedbackabout accomplishments.


Fatigue 345

••••••


• Identification of circumstances in the client’s environ-ment that support continuing feelings of fatigue (e.g.,family stressors or secondary gain from fatigue)

• Identification of the client’s accomplishments

After the client has verbalized the effects negativethoughts have on feelings and behavior, teach the clienthow to stop negative thoughts and replace them withpositive thoughts.

Reward the client for positive self-statements withinformative positive verbal reinforcement.

Assign the client tasks on the unit, and provide positivereinforcement for task accomplishment. [Note taskassigned and reward established here.]

Involve the client in group activity with other clients for[number] minutes [number] times a day.

Meet with the client and client’s family to evaluate inter-action patterns and provide information that wouldassist them in assisting the client.

Have the client identify those factors that will maintaina feeling of well-being after discharge, and develop aspecific behavioral plan for implementing them. [Noteplan here.]

Cognitive maps impact feelings and behavior. When cog-nitive maps are used inappropriately, they can promotemaladaptive thinking, behaving, and feeling.Recognition of dysfunctional maps provides the clientwith the opportunity for developing positive orientationand adaptive cognitive maps.37


Interaction with peers provides opportunities to increasesocial network, learn problem-solving strategies,and test perceptions of self and experiences withpeers.

Family support enhances probability of behavior changesbeing maintained after discharge.

Reinforces behavior change and new coping skills, whileproviding positive feedback and enhancing self-esteem.37

Gerontic Health


Review medications for side effects or possible druginteractions.

Collaborate with the health-care team in assessing thepatient for depression.

Collaborate with the health-care team in assessing thyroidfunction and hormone levels.

Monitor for activities that interrupt the patient’s sleep pat-tern, such as taking vital signs, daily weights, or treat-ments.

Carefully assess sleep patterns and sleep hygiene andmake recommendations for improvement as needed.

Avoid bedrest when possible.

Collaborate with the health-care team to provide gradedaerobic exercise.

Plan care activities around periods of least fatigue.

Many medications can contribute to the sensation offatigue, particularly cardiac and antihypertensive med-ications, high-dose or replacement corticosteroids,antivirals, antifungals, and immune therapy.73

Depression is often underreported and undertreated inolder adults.

Alterations in thyroid function and hormone levels canlead to fatigue.

Environmental noises and inattention to the patient’susual sleep pattern may result in sleep fragmentation.

Sleep deprivation can lead to fatigue.

Bedrest and sedentary lifestyle can contribute to fatigue.

Graded aerobic activity offers benefit in cases offatigue.73

Gives attention to the patient’s circadian rhythm.(care plan continued on page 346)



••••••




Assist the patient and family in identifying risk factorspertinent to the situation:

• Chronic disease (e.g., arthritis, cancer, or heart disease)• Medications• Pain• Role strain

Teach the client and family measures to enhance capacityfor physical and mental work:

• Use of assistive devices as appropriate (wheelchairs,crutches, canes, walkers, adaptive eating utensils, etc.)

• Maintain sufficient pain control.• Provide a safe environment to reduce physical barriers

to mobility (throw rugs, stairs, blocked pathways, etc.)and decrease potential for accidents.

• Provide balance of work and recreational activities.• Assess client/family need for in-home support and pro-

vide referrals as needed to appropriate communityresources such as tutors, Meals on Wheels, housekeep-ing assistance, daily hygiene assistance.


Promotes self-care and safety.

GAS EXCHANGE, IMPAIRED

DEFINITION22

Excess or deficit in oxygenation and/or carbon dioxide elim-ination at the alveolar–capillary membrane.


1. Visual disturbances2. Increased carbon dioxide3. Tachycardia4. Hypercapnia5. Restlessness6. Somnolence7. Irritability8. Hypoxia9. Confusion

10. Dyspnea11. Abnormal arterial blood gases12. Cyanosis (in neonate only)13. Abnormal skin color (pale, dusky)14. Hypoxemia15. Hypercarbia16. Headache upon awakening17. Abnormal rate, rhythm, and depth of breathing18. Diaphoresis19. Abnormal arterial pH20. Nasal flaring

RELATED FACTORS22

1. Ventilation perfusion imbalance2. Alveolar–capillary membrane changes


1. Chronic obstructive pulmonary disease (COPD)2. Congestive heart failure3. Asthma4. Pneumonia5. Pulmonary tuberculosis


Ineffective Airway ClearanceThis diagnosis means that something is blocking theair passage but that, when and if air gets to the alve-oli, there is adequate gas exchange. In Impaired GasExchange, the air (oxygen) that reaches the alveoli isnot sufficiently diffused across the alveolar–capillarymembrane.

Ineffective Breathing PatternThis diagnosis suggests that the rate, rhythm, depth,and type of ventilatory effort are insufficient to bring inenough oxygen or get rid of sufficient amounts of car-bon dioxide. These gases are sufficiently exchanged


Gas Exchange, Impaired 347

••••••

at the alveoli-circulatory membrane, but the pattern ofventilation makes breathing ineffective.

Decreased Cardiac OutputIn this diagnosis, the heart is not pumping a sufficientamount of blood through the lungs to take up enoughoxygen or release enough carbon dioxide to meet thebody requirements. There is no impairment in the gasexchange, but there is not enough circulating blood tocombine with sufficient amounts of oxygen to supplythe body’s needs.

EXPECTED OUTCOME

Will demonstrate improved blood gases and vital signs by[date]. Note initial blood gas measurements and vital signshere.

TARGET DATESBecause of the extreme danger of Impaired Gas Exchange,progress should be evaluated at least every 8 hours until theclient has stabilized. Thereafter, target dates at 3 to 5 daysare acceptable.


Adult Health


Perform nursing actions to maintain effective airwayclearance. (See Ineffective Airway Clearance for nurs-ing actions, and enter those actions here.)

Analyze lab work including arterial blood gases andhemoglobin and hematocrit.

Position the patient to optimize gas exchange:• Raise head of bed to 30 degrees or more if not con-

traindicated.• Position the patient with the “good lung down.”• Collaborate with the health-care team regarding prone

positioning.

Maintain adequate nutrition. Collaborate with diet thera-pist regarding several small meals per day rather thanthree large meals.

Have the patient practice exercises such as incentivespirometer or pursed lipped breathing once every hourwhile the patient is awake.

Provide teaching regarding respiratory exercises:• Assume a sitting position with back straight and shoul-

ders relaxed.• Use conscious, controlled deep-breathing techniques

that expand diaphragm downward (abdomen shouldrise).

• Breathe in deeply through the nose, hold for 2 to 3 sec-onds, and then breathe out slowly through pursed lips.Abdomen will sink down with the exhalation.

Assist with postural drainage and chest physiotherapy.Teach these exercises to significant other.

Administer bronchodilators and mucolytic agents as pre-scribed.

Collaborate with the health-care team regarding monitor-ing of blood gases.

Turn every 2 hours on [odd/even] hour. Encourage thepatient’s mobility to the extent tolerated withoutdyspnea.

Clearing airways of secretions improves ventilation–perfusion relationship.

Will provide integral information to determine deficits incapacity and effect of oxygen delivery.

Facilities chest expansion.

Promotes gas exchange and with alveolar recruitment.

Decreases energy demand for digestion, and preventsconstriction of chest cavity as a result of a fullstomach.

Promotes alveolar open.

PCO2, PO2, and O2 saturation are indicators of the effi-ciency of gas exchange.

Position changes modify ventilation–perfusion relation-ships and enhance gas exchange.




••••••


Adult Health


Provide for periods of activity and rest.

Discuss with the patient the effects smoking has on therespiratory system, and refer the patient to a stopsmoking group if the patient is motivated to stop smok-ing. If the patient is not motivated to stop smoking,instruct the patient not to smoke 15 minutes beforemeals and physical activity.

Review the patient’s resources and home situation regard-ing long-term management of Impaired Gas Exchangebefore discharge. Refer to appropriate communityresources.

Conserves energy needed for breathing and decreasedoxygen consumption.

Smoking, or passive smoke for the nonsmoker, greatlyincreases the risk for development of respiratory andcardiovascular diseases. Smoking immediately beforeeating or exercise causes vasoconstriction, leadingto decreased gas exchange, and compounding thecondition.

Initiates appropriate home care planning and long-rangesupport for the patient and family.

Child Health


Monitor contributing factors, especially current medicalstatus and respiratory demands.

Ensure availability of emergency equipment as appro-priate:

• Ambu bag• Endotracheal tube appropriate for age and size of infant

(3.5)• Suctioning unit and catheters: infant, 5 or 8 Fr; child, 8

or 10 Fr• Crash cart with appropriate drugs• Defibrillation unit with guidelines• O2 tank (check amount of oxygen left)• Tracheostomy sterile set• Sterile chest tube tray

Provide for parental input in planning and implementingcare (e.g., comfort measures, assisting with feedings,and daily hygienic measures).

Allow at least 10 to 15 minutes per shift for the family toverbalize concerns regarding the child’s status andchanges. Encourage the parents to ask questions asoften as needed.

Collaborate with related health-care team members asneeded.

While the child is still in the hospital, provide opportuni-ties for the parents and child to master essential skillsnecessary for long-term care, such as suctioning.

Schedule parents and family for CPR training well beforedismissal from hospital. [Note time and responsibleperson here.]


Parental involvement provides emotional security for thechild’s parents; offers empowerment and allows prac-ticing of care techniques in a supportive environment.

Assists in reducing anxiety, and provides teaching oppor-tunity.

Promotes coordination of care without undue duplicationand fragmentation of care.

Learning of essential skills is enhanced when opportuni-ties for practice are allowed in a safe, secure environ-ment. Compliance is also fostered.

Anticipatory need for CPR should better prepare parentsand other family members in the event of pulmonaryarrest. Having this basic knowledge will assist inreducing anxiety regarding home care.



••••••


Facilitate the parents’ use of the support system to aid incoping with illness and hospitalization.

Allow for sibling visitation as applicable within institu-tion or specific situation.

Administer medications that are ordered. Monitor forvariable response in child especially antibiotics, corti-costeroids (inhaled and IV).

Teach the child and family about needs for follow-up careand protection from triggering events, including expo-sure to respiratory infections.

Refer to appropriate community agencies for supportafter discharge. [Note those referral agencies here.]

Reliance on others should afford the parents some degreeof relief from constant worry based on the likelihoodof primary needs with a chronically ill child.

Sibling visitation enhances the opportunity for familycoping and growth. Provides moral support to bothsiblings.

Provides anticipatory guidance with safe administrationof medications.

Reinforces need for realistic plan of follow-up and antic-ipatory prevention.

Offers support to child and family.

Women’s Health

● N O T E : This nursing diagnosis will pertain to women the same as in any other adult.The following nursing actions focus only on the fetal–placental unit during pregnancy.Placental function is totally dependent on maternal circulation; therefore, any processthat interferes with maternal circulation will affect the oxygen consumption of the pla-centa and, in turn, the fetus.


Assist the patient in developing an exercise plan duringpregnancy.

Teach the patient and significant others how to avoid“supine hypotension” during pregnancy (particularlyduring the later stages):

• Lying on right or left side to reduce pressure on venacava

• Taking frequent rest breaks during the day

Assist the patient in identifying lifestyle adjustments thatmay be needed because of changes in physiologicfunction or needs during pregnancy:

• Stop smoking.• Reduce exposure to secondhand smoke.• Avoid lying in the supine position.• Take no drugs unless advised to do so by physician.

Identify underlying maternal diseases that will affect thefetal–placental unit during pregnancy:

• Maternal origin:• Maternal hypertension• Drug addiction• Diabetes mellitus with vascular involvement• Sickle cell anemia• Maternal infections• Maternal smoking• Hemorrhage (abruptio placentae or placenta previa)

Increases cardiovascular fitness, and therefore increasesoxygenation and nutrition to placenta and fetus.

These disorders have direct impact on the gas exchangein the fetal–placental unit.




••••••


Women’s Health


• Fetal origin:• Premature or prolonged rupture of membranes• Intrauterine infection• RH disease• Multiple pregnancy

Mental Health

In addition to the nursing interventions for Adult Health, the following interventions applyto specific Mental Health situations:


If the client is demonstrating alterations in mental status,assess for increased hypoxia.

Observe the client for signs of respiratory infection.

Protect the client from respiratory infection by:• Maintaining proper humidity in the environment.• Observe the client closely for signs and symptoms of

respiratory infection. If infection is present, and theclient is sharing a room, move the roommate to anotherroom.

• Arrange staff assignments so that staff who care forclients with infections are not also caring for clientswho are free of infection.

• Keeping the client away from crowds.• Assisting the client in obtaining appropriate immuniza-

tions against influenza.• Having the client inform staff of signs or symptoms of

respiratory infection when the earliest symptomsappear.

• Keeping environment as free of respiratory irritants aspossible (e.g., dust, allergens, or pollution).

• Provide the client with equipment required to maintainadequate oxygenation. [Note that equipment and spe-cial adaptations here.]

• Collaborate with respiratory therapy to provide clienteducation about proper use of the equipment.

Discuss with the client the effects of alcohol and otherdepressant drugs on the respiratory system. Refer to adrug-abuse recovery program as necessary.

Collaborate with physician regarding supplemental vita-mins, especially thiamine, if the impaired gas exchangeis secondary to alcohol abuse.

The central nervous system is particularly sensitive toimpaired gas exchange because of its reliance on sim-ple sugar metabolism for energy production.66

Infection will increase mucus production, whichdecreases airway clearance.66

Prevents further injury to a system that is stressed, andpromotes airway patency.

The sedative effects of some drugs decrease airway clear-ance, increasing the risk for the development of infec-tion. Diffusion is also decreased with chronicalcoholism.77

Thiamine is essential for the conversion of glucose tometabolically useful forms. Nerve cell functiondepends on this glucose. This compensates for thenutritional deficits that result when nutritional caloriesare replaced by alcohol.78



••••••


Spend [number] minutes [number] times a day with theclient discussing feelings and reactions to current sit-uation. As feelings are expressed, begin to explorelifestyle changes with the client. Refer to IneffectiveIndividual Coping (Chapter 11) and Powerlessness(Chapter 8) for specific care plans related to copingstyles.

Develop with the client a plan for gradually increasingphysical activity. (See Activity Intolerance for specificbehavioral interventions.)

Promotes the client’s sense of control by facilitatingunderstanding of factors that contribute to maladaptivecoping behaviors.

Improves cardiorespiratory functioning, thus improvinggas exchange.

Gerontic Health


Ensure that oxygen delivery system is properly function-ing and fits well. Avoid face mask if the patient is ema-ciated. Check proper positioning of nasal cannula(prongs turned inward), and ensure that all oxygen ishumidified.

Monitor skin color, mental status, and vital signs every2 hours on [odd/even] hour.

Check oxygen flow and amount every 4 hours around theclock at [times].

Monitor for potential carbon dioxide narcosis (e.g.,changes in level of consciousness, changes in oxygenand carbon dioxide blood gas levels, flushing,decreased respiratory rate, and headaches). This isespecially important for a patient on long-term oxygentherapy.58

Teach the patient and family the signs and symptoms ofcarbon dioxide narcosis, especially those on long-termoxygen therapy.

Basic care standards.

The patient may increase the liter flow during acuteepisodes of impaired gas exchange and cause res-piratory system depression with retention of carbondioxide.

Decreases potential for carbon dioxide narcosis.

Home Health

● N O T E : If this diagnosis is suspected when caring for a client in the home, it isimperative that a physician referral be obtained immediately. If a physician has referredthe client to home health care, the nurse will collaborate with the physician in the treat-ment of the client. Preliminary research77 indicates that women with chronic bronchitisor chronic obstructive pulmonary disease (COPD) cannot walk as far as men. Activityshould be planned according to tolerance, keeping in mind gender differences. There isno doubt that better control of dyspnea is a pressing need, with research79 indicatingthat a client’s subjective report of health status is a better predictor of level of function-ing than is objective measure of the lung function.


Teach the client and family appropriate monitoring ofsigns and symptoms of Impaired Gas Exchange:





••••••


Home Health


• Pursed-lip breathing• Respiratory status: cyanosis, rate, dyspnea, or

orthopnea• Fatigue• Use of accessory muscles• Cough• Sputum production or change in sputum production• Edema• Decreased urinary output• Gasping


Prevention of Impaired Gas Exchange: Stopping smok-ing, prevention or early treatment of lung infections,avoidance of known irritants and allergens, obtainingannual influenza and pneumonia immunizations.

• Pulmonary hygiene: clearing bronchial tree by con-trolled coughing, decreasing viscosity of secretions viahumidity and fluid balance, and postural drainage

• Daily activity as tolerated (remove physical barriers tomobility/activity)

• Breathing techniques to decrease work of breathing(diaphragmatic, pursed lips, or sitting forward)

• Adequate nutrition intake• Appropriate use of oxygen (dosage, route of adminis-

tration, safety factors). Ensure that the patient and care-giver understand the risks associated with smoking inthe presence of supplemental oxygen.

• Stress management• Limiting exposure to upper respiratory infections• Avoiding extreme hot or cold temperatures• Keeping area free of animal hair and dander or dust• Assistive devices required (oxygen, nasal cannula, suc-

tion, ventilator, etc.)• Adequate hydration (monitor intake and output)

Teach the client and family purposes, side effects, andproper administration technique of medications.

Assist the client and family to set criteria to help themdetermine when calling a physician or other interven-tion is required (e.g., change in skin color, increaseddifficulty with breathing, increase or change in sputumproduction, or fever).


Assess the client/family need for additional resources andrefer to community resources, as appropriate.


To promote adequate self-care and to prevent complica-tions from untoward medication side effects.

To promote adequate self-care and facilitate timely acqui-sition of professional health care as needed.




Growth and Development, Delayed; Disproportionate Growth, Risk For; Delayed Development, Risk For 353

••••••

GROWTH AND DEVELOPMENT,DELAYED; DISPROPORTIONATEGROWTH, RISK FOR; DELAYEDDEVELOPMENT, RISK FOR

DEFINITIONS22

Delayed Growth and Development The state in which anindividual demonstrates deviations in norms from his or herage group.

Risk for Disproportionate Growth At risk forgrowth above the 97th percentile, or below the 3rd per-centile for age, crossing two percentile channels; or dispro-portionate growth.

Risk for Delayed Development At risk for delay of25 percent or more in one or more of the areas of social orself-regulatory behaviors, or cognitive, language, gross, orfine motor skills.


A. Delayed Growth and Development1. Altered physical growth2. Delay or difficulty in performing skills (motor, social,

or expressive) typical of age group3. Inability to perform self-care or self-control activities

appropriate to age4. Flat affect5. Listlessness6. Decreased responses

B. Risk for Disproportionate Growth1. Prenatal

a. Congenital or genetic disordersb. Maternal nutritionc. Multiple gestationd. Teratogen exposuree. Substance use or abusef. Infection

2. Individuala. Infectionb. Prematurityc. Malnutritiond. Organic and inorganic factorse. Caregiver and/or individual maladaptive feeding

behaviorsf. Anorexiag. Insatiable appetiteh. Chronic illnessi. Substance abuse

3. Environmentala. Deprivationb. Teratogenc. Lead poisoningd. Povertye. Violencef. Natural disasters

4. Caregivera. Abuseb. Mental illnessc. Mental retardationd. Severe learning disability

C. Risk for Delayed Development1. Prenatal

a. Maternal age less than 15 or greater than 35 yearsb. Substance abusec. Infectionsd. Genetic or endocrine disorderse. Unplanned or unwanted pregnanciesf. Lack of, late, or poor prenatal careg. Inadequate nutritionh. Illiteracyi. Poverty

2. Individuala. Prematurityb. Seizuresc. Congenital or genetic disordersd. Positive drug screening teste. Brain damage (e.g., hemorrhage in postnatal

period, shaken baby, abuse, accident)f. Vision impairmentg. Hearing impairment or frequent otitis mediah. Chronic illnessi. Technology-dependentj. Failure to thrivek. Inadequate nutritionl. Foster or adopted childm. Lead poisoningn. Chemotherapyo. Radiation therapyp. Natural disasterq. Behavioral disorderr. Substance abuse

3. Environmentala. Povertyb. Violence

4. Caregivera. Abuseb. Mental illnessc. Mental retardation or severe learning disability

RELATED FACTORS22

A. Delayed Growth and Development1. Prescribed dependence2. Indifference3. Separation from significant others4. Environmental and stimulation deficiencies5. Effects of physical disability6. Inadequate caretaking7. Inconsistent responsiveness8. Multiple caretakers



••••••

B. Risk for Disproportionate GrowthThe risk factors also serve as the related factors.

C. Risk for Delayed DevelopmentThe risk factors also serve as the related factors.


1. Hypothyroidism2. Failure to thrive syndrome3. Leukemia4. Deficient growth hormone5. Personality disorders6. Schizophrenic disorders7. Substance abuse8. Dementia9. Delirium


Disturbed Sensory PerceptionThis diagnosis should be considered when blindness,deafness, or neurologic impairment is present.Assisting the patient to adapt to these problemscould resolve any developmental problems.

Impaired Physical MobilityWhen physical disabilities are present, they candefinitely impact growth and development. In thisexample, Impaired Physical Mobility and Delayed

Growth and Development would be companiondiagnoses.

Imbalanced Nutrition, LessThan Body RequirementsLack of essential vitamins and minerals will also showa direct link to Delayed Growth and Development.Assessment should be implemented for both diag-noses.

The nursing diagnoses grouped under Self-Perception and Self-Concept Pattern, Role-Relationship Pattern, and Coping-Stress TolerancePattern should also be considered when alterations ingrowth and development are present.

EXPECTED OUTCOME

Will return, as nearly as possible, to expected growth anddevelopment parameter for [specify exact parameter] by[date].

TARGET DATES

Assisting in modifying Delayed Growth and Developmentfactors will require significant time; therefore, an initial tar-get date of 7 to 10 days would be reasonable for evaluatingprogress.


Adult Health

● N O T E : Nursing actions for this diagnosis are varied and complex and incorporatenursing actions associated with other nursing diagnoses. For example, the patient mayhave either a total self-care deficit or a deficit in hygiene, grooming, feeding, or toilet-ing. For an adult, any of these would be an alteration in growth and development.Therefore, it would be appropriate to include the nursing actions associated with thesenursing diagnoses in the nursing actions for Delayed Growth and Development.

An adult is generally able to find or initiate diversional and social activities.However, if the adult does not participate in diversional or social activities, it couldindicate Delayed Growth and Development. Therefore, the nursing actions associatedwith Deficient Diversional Activity and Social Isolation would be appropriate to beincluded in the nursing actions for Delayed Growth and Development.


In general, the nurse should provide adequate opportuni-ties for the patient to be successful in whatever task heor she is attempting.

Reward and reinforce success, however minor. Downplayrelapses. Allow the patient to be as independent aspossible.

Have consistent, nonjudgmental, caring people in thecaregiving role.

Work collaboratively with other health-care professionalsand with the patient and family in developing a planof care.

Success increases motivation.

Increases self-esteem and active participation in care.

Caring people instill confidence in a patient and willing-ness to try new tasks.

Facilitates development of a plan that all will use consis-tently.



••••••

Child Health


Monitor and teach the parents to monitor the child’sgrowth and development status. Determine what alter-ations there are (i.e., delays or precocity).

Determine what other primary health-care needs exist,especially brain damage or residuals of brain damage.

Identify, with the child or the parents, realistic goals forgrowth and development.

Collaborate with related health-care team members asnecessary. [Note those providers involved here with aplan for their involvement.]

Identify anticipatory safety for the child related toDelayed Growth and Development (e.g., ingestion ofobjects, falls, or use of wheelchair). [Note specialsafety adaptations that are needed for this child here.]

Teach parents special diet necessitated by a metabolicdisorder (e.g., various enzymes lacking).

Refer the child and parents to appropriate communityresources to assist in fostering growth and develop-ment, such as the early childhood intervention services.

Assist the parents to provide for learning needs related tofuture development, including identification of schoolsfor developmentally delayed children.

Refer the child and parents to state and national supportgroups such as National Cerebral Palsy Association.

Provide the patient and family with long-term follow-upappointments before discharge.

As a rule, single assessments are not as revealing ingrowth and development parameters as are serial, lon-gitudinal patterns. Parental involvement offers a morethorough monitoring, fosters their involvement with thechild, and empowers the family.

In instances of brain damage or retardation, it is often dif-ficult to get an accurate assessment of cognitive capa-bility. The general health of the patient will often influ-ence, to a major degree, what alteration in cognitivefunctioning exists (e.g., sickle cell anemia with result-ant infarcts to major organs such as the brain).

A plan of care based on individual needs, with parentalinput, better reflects holistic care and increases proba-bility of effective home management of problem.

Collaboration is required for meeting the special long-term needs for activities of daily living.

These children may be large physically because ofchronologic age, and there is a possibility of overlook-ing the developmental or mental age.

Appropriate diet can assist in preventing further deterio-ration or be essential to replace lacking vitamins,enzymes, or other nutrients.

Offering early intervention assists in fostering develop-ment, while preventing tertiary delays.

Appropriate match of services to needs enhances thechild’s development to the highest level possible.

Support groups assist in empowerment and advocacy atlocal, state, and national levels.

Promotes implementation of management regimen, andprovides anticipatory resources and checkpoint for thepatient and family.

Women’s Health

● N O T E : The same nursing diagnosis pertains to Women’s Health as to Adult Health.The following nursing actions pertain only to women with reproductive anatomic abnor-malities. The mother does need to be aware of the normal growth patterns in order toassess the health and development of her child. See Child Health.


Obtain a thorough sexual and obstetric history, especiallynoting recurrent miscarriages in the first 3 months ofpregnancy.

Collaborate with the physician regarding assessment forinfertility.

Provides a basic database for determining therapy needs.




••••••


Women’s Health


Refer to a gynecologist for further testing if primaryamenorrhea is present.

Encourage the patient to verbalize her concerns and fears.

Encourage communication with significant others to iden-tify concerns and explore options available.

Decreases anxiety. Allows an opportunity for teaching,and allows correction of any misinformation.

Provides a base for teaching and long-range counseling.

Mental Health

● N O T E : If anorexia nervosa is the underlying cause for growth risk, refer to theMental Health care plan for the diagnosis Imbalanced Nutrition, Less Than BodyRequirements, for the appropriate intervention.


Provide a quiet, nonstimulating environment, or an envi-ronment that does not place additional stress on analready overwhelmed coping ability.

Sit with the client [number] minutes [number] times perday at [list specific times] to discuss current concernsand feelings.

Provide the client with familiar or needed objects. Theseshould be noted here.

Discuss with the client perceptions of self, others, and thecurrent situation. This should include the client’s per-ceptions of harm, loss, or threat. Assist the client inaltering perception of these situations so they can beseen as challenges or opportunities for growth ratherthan threats.

Provide the client with an environment that will optimizesensory input. This could include hearing aids,eyeglasses, pencil and paper, decreased noise in con-versation areas, and appropriate lighting. These inter-ventions should indicate an awareness of sensorydeficit as well a sensory overload, and the specificinterventions for the client should be noted here (e.g.,place hearing aid in when the client awakens, andremove before bedtime).

Provide the client with achievable tasks, activities, andgoals (these should be listed here). These activitiesshould be provided with increasing complexity to givethe client an increasing sense of accomplishment andmastery.

Too little or too much sensory input can result in a senseof disorganization and confusion and result in dysfunc-tional coping behaviors.35

Attention from the nurse can enhance self-esteem.Expression of feelings can facilitate identification andresolutions of problematic coping behaviors.

Promotes the client’s sense of control by providing anenvironment in which the client feels safe and secure.

Provides positive orientation, which improves self-esteemand provides hope for the future.

Appropriate levels of sensory input promote contact withthe reality of the environment, which facilitates appro-priate coping.

Provides positive reinforcement, which enhances self-esteem and provides motivation for working toward thenext goal.



••••••


Communicate to the client an understanding that all cop-ing behavior to this point has been his or her best effortand asking for assistance at this time is not failure.Explain that a complex problem often requires someoutside assistance in resolution. (This will assist theclient in maintaining self-esteem and diminish feelingsof failure.)

Provide the client with opportunities to make appropriatedecisions related to care at his or her level of ability.This may begin as a choice between two options andthen evolve into more complex decision making. It isimportant that this be at the client’s level of function-ing so confidence can be built with successful decision-making experiences.

Provide constructive confrontation for the client aboutproblematic coping behavior. (See Wilson and Kneisl32

for guidelines on constructive confrontation.) Thekinds of behavior identified by the treatment team asproblematic should be listed here.

Provide the client with opportunities to practice newkinds of behavior either by role playing or by applyingthem to graded real-life experiences.

Provide positive social reinforcement and other behav-ioral rewards for demonstration of adaptive behavior.(Those things that the client finds rewarding should belisted here with a schedule for use. The kinds of behav-ior that are to be rewarded should also be listed.)

Assist the client in identifying support systems and indeveloping a plan for their use.

Assist the client with setting appropriate limits on aggres-sive behavior by (see Risk for Violence, Chapter 9,for detailed nursing actions if this is an appropriatediagnosis):

• Decreasing environmental stimulation as appropriate.(This might include a secluded environment.)

• Providing the client with appropriate alternative outletsfor physical tension. (This should be stated specificallyand could include walking, running, talking with a staffmember, using a punching bag, listening to music, ordoing a deep muscle relaxation sequence. These outletsshould be selected with the client’s input.)

Meet with the client and support system to provide infor-mation on the client’s situation and to develop a planthat will involve the support system in making changesthat will facilitate the client’s movement to age-appro-priate behavior. [Note this plan here.]


Promotes positive orientation, which enhances self-esteem and promotes hope.

Promotes the client’s perception of control, which pro-motes self-esteem.

Provides opportunities for the client to question aspectsof behavior that can promote a desire to change.

Provides opportunities to practice new behavior in a safeenvironment where the nurse can provide positive feed-back for gradual improvement of coping strategies.This increases the probability for the success of thenew behavior in real-life situations, which in turnserves as positive reinforcement for behavior change.


Support systems can provide positive reinforcement forbehavior change, increasing the opportunities for theclient’s success enhancing self-esteem.

Excessive environmental stimuli can increase a sense ofdisorganization and confusion.

Promotes a sense of control, and teaches constructiveways to cope with stressors.

Enhances opportunities for success of the treatment plan.




••••••


Gerontic Health

Nursing interventions provided in the Adult Health and Home Health sections for this diagnosis may be enhanced for theolder client with the addition of the following actions.


Provide opportunities for clients to reflect on theirstrengths and life accomplishments through activitiessuch as life review, reminiscing, and oral or writtenautobiographies.

Consult with the physician for potential assessment andtreatment of depression.

Ask older clients what tasks of aging they have definedfor themselves.

Promotes ability to obtain perspective on lifeexperiences.80 Provides potential for enhancing life sat-isfaction.80

Depression often goes undetected in older adults and maynegatively impact their ability to effectively cope withlosses and to positively appraise their currentsituation.80

Promotes discussion of the older adult’s expectations.81

Home Health


Monitor for factors contributing to Delayed Growth andDevelopment.

Involve the client and family in planning, implementing,and promoting reduction or correction of the delay ingrowth and development:


Teach the client and family measures to prevent ordecrease delays in growth and development:

• Explain expected norms of growth and developmentwith anticipatory guidance. If the caretakers realize, forexample, that the newborn begins to roll over by 2 to 4months or that the 2-year-old can follow simple direc-tions, then appropriate environmental and learning con-ditions can be provided to protect the child and topromote optimal development.

• Alert the parents to signs and symptoms of alterationsin growth and development that may require profes-sional evaluation (e.g., delay in language skills, delayin crawling or walking, or delay in growth below50 percent on growth chart).

• Teach parents how to recognize developmental mile-stones and their expected/associated behaviors andhow to discipline effectively without violence.

• Provide guidance on developmentally appropriate nutri-tion (e.g., how to introduce finger foods to toddlers,how to monitor calorie intake for expected develop-mental stage, and how to ensure a balanced diet).


• Care for handicaps (e.g., blindness, deafness, or mus-culoskeletal or cognitive deficit)

Provides a database for prevention and/or early interven-tion.






••••••


• Proper use of assistive equipment• Adapting to need for assistance or assistive equipment• Determining criteria for monitoring the client’s ability

to function unassisted• Time management• Stress management• Development of support systems• Learning new skills• Work, family, social, and personal goals and priorities• Coping with disability or dependency• Development of consistent routine• Mechanism for alerting family members to the need for

assistance• Providing appropriate balance of dependence and inde-

pendence

Assess the client/caregiver need for assistive equipmentor supplies and assist the client and family to obtainassistive equipment as required (depending on alter-ation present and its severity):

• Adaptive equipment for eating utensils, combs,brushes, etc.

• Straw and straw holder• Wheelchair, walker, motorized cart, or cane• Bedside commode or incontinence undergarments• Hearing aid• Corrective lenses• Dressing aids: dressing stick, zipper pull, button hook,

long-handled shoehorn, shoe fasteners, or Velcro closures• Bars and attachments and benches for shower or tub• Handheld shower device• Medication organizers• Magnifying glass• Raised toilet seat

Assess the client/family need for in home assistance(daily hygiene, housework, meal delivery services) andrefer to community resources as appropriate.

Assist the client or caregivers in obtaining prescribedmedications, and ensure that they understand doses,administration times, therapeutic effects, and possibleside effects.

If the client is a child, the nurse can serve as a liaisonbetween the school nurse, family, and primary physi-cian to monitor effectiveness of therapy and to provideanticipatory guidance for family members.

Instruct the client as appropriate and the caregivers tomaintain a consistent home environment (e.g., sched-ules, parenting, and goal setting). The home environ-ment should be free of distractions when it is necessaryfor the client to perform tasks.

Refer clients and family members for counseling, specialtraining (e.g., parenting classes), or support groups asnecessary.

Assistive equipment improves function and increases thepossibilities for self-care.


Promotes adherence to the therapeutic regimen.

Provides continuity of care.

Consistency can promote success and focus on thestrengths of the client.

Helps develop healthier self-esteem and positive copingstrategies.



••••••

HOME MAINTENANCE, IMPAIRED

DEFINITION22

Inability to independently maintain a safe growth-promotingimmediate environment.21


1. Objectivea. Overtaxed family members, for example, exhausted,

anxiousb. Unwashed or unavailable cooking equipment, clothes,

or linenc. Repeated hygienic disorders, infestations, or infec-

tionsd. Accumulation of dirt, food wastes, or hygienic wastese. Disorderly surroundingsf. Presence of vermin or rodentsg. Inappropriate household temperatureh. Lack of necessary equipment or aidsi. Offensive odors

2. Subjectivea. Household members express difficulty in maintaining

their home in a comfortable fashion.b. Household members describe outstanding debts or

financial crises.c. Household members request assistance with home

maintenance.

RELATED FACTORS22

1. Individual or family member disease or injury2. Unfamiliarity with neighborhood resources3. Lack of role modeling4. Lack of knowledge5. Insufficient family organization or planning6. Impaired cognitive or emotional functioning7. Inadequate support systems8. Insufficient finances


1. Dementia problems, such as Alzheimer’s disease2. Rheumatoid arthritis3. Depression4. Cerebrovascular accident5. Acquired immunodeficiency syndrome (AIDS)


Activity IntoleranceIf the nurse observes or validates reports of thepatient’s inability to complete required tasks because

of insufficient energy, then Activity Intolerance wouldbe the more appropriate diagnosis.

Deficient KnowledgeThe problem with home maintenance may be due tothe family’s lack of education regarding the careneeded and the environment that is essential to pro-mote this care. If the patient or family verbalizes less-than-adequate understanding of home maintenance,then Deficient Knowledge is the more appropriatediagnosis.

Disturbed Thought ProcessIf the patient is exhibiting impaired attention span;impaired ability to recall information; impaired percep-tion, judgment, and decision making; or impaired con-ceptual and reasoning ability, the most properdiagnosis would be Disturbed Thought Process. Mostlikely, Impaired Home Management would be a com-panion diagnosis.

Ineffective Individual Coping orCompromised or Disabled Family CopingSuspect one of these diagnoses if there are major dif-ferences between reports by the patient and the fam-ily of health status, health perception, and health carebehavior. Verbalizations by the patient or the familyregarding inability to cope also require looking atthese diagnoses.

Interrupted Family ProcessesThrough observing family interactions and communi-cation, the nurse may assess that Interrupted FamilyProcesses should be considered. Poorly communi-cated messages, rigidity of family functions and roles,and failure to accomplish expected family develop-mental tasks are a few observations to alert the nurseto this possible diagnosis.

EXPECTED OUTCOME

Will demonstrate alterations necessary to reduce ImpairedHome Maintenance by [date].

Will describe a plan to improve household safety by[date].

Describes plan for allocation of family responsibili-ties to maintain home in a safe comfortable condition by[date].

TARGET DATES

Target dates will depend on the severity of the ImpairedHome Maintenance. Acceptable target dates for the firstevaluation of progress toward meeting this outcome wouldbe 5 to 7 days.


Home Maintenance, Impaired 361

••••••


Adult Health

A nurse in an acute care facility might receive enough information while the patient is hospitalized to make this nursingdiagnosis. However, nursing actions specific for this diagnosis will require implementation in the home environment;therefore, the reader is referred to the Home Health nursing actions for this diagnosis.

Child Health


Monitor risk factors of or contributing factors to ImpairedHome Maintenance, to include:

• Addition of a family member (e.g., birth)• Increased burden of care as a result of the child’s ill-

ness or hospitalization• Lack of sufficient finances• Loss of family member (e.g., death)• Hygienic practices• History of repeated infections or poor health manage-

ment• Offensive odors

Identify ways to deal with home maintenance alterationswith assistance of applicable health team members.

Allow for individual patient and parental input in plan foraddressing home maintenance issues.

Monitor educational needs related to illness and thedemands of the situation (e.g., mother who must attendto a handicapped child and six other children with vari-ous school appointments, health care appointments, etc.)

Provide health teaching with sensitivity to the patient andfamily situation (e.g., seeming inability to manage withoverwhelming demands of the child’s need for care,such as a premature infant or a child with cerebralpalsy who has feeding difficulties).

Provide 10 to 15 minutes each 8-hour shift as a time fordiscussion of patient and family feelings and concernsrelated to health management.

Provide the patient and family with information aboutsupport groups in the community. Arrange contact withgroups that would provide the most support beforedischarge.

If the infant is at risk for sudden infant death syndrome(SIDS) by nature of prematurity or history of previousdeath in family, assist parents in learning about alarmsand monitoring respiration, and institute CPR teaching.

Refer to community and primary care providers forfollow-up after discharge from the hospital.

Provides primary database for intervention.

Coordinated activities will be required to meet the entirerange of needs related to improving problems withhome maintenance.

Parental input offers empowerment and attaches value tofamily preferences. This in turn increases the likeli-hood of compliance.

Monitoring of educational needs balanced with the homesituation will best provide a base for intervention.

Teaching to address identified needs reduces anxiety andpromotes self-confidence in ability to manage.

Setting aside times for discussion shows respect andassigns value to the patient and family.

Support groups empower and facilitate family coping.

When risk factors for pulmonary arrest are present as, forexample, for a SIDS infant, family members will be lessanxious if they are taught CPR techniques and givenopportunities to rehearse and master these techniques.

Follow-up plans provide a means of further evaluation forprogress in coping with home maintenance. Ideally,actual home visitation allows the best opportunity formonitoring goal achievement.




••••••


Women’s Health


Assist the client to describe her perception or understand-ing of home maintenance as it relates to her lifestyleand lifestyle decisions. Include stress-related problemsand effects of environment:

• Allow the patient time to describe work situation.• Allow the patient time to describe the home situation.• Encourage the patient to describe how she manages her

responsibilities as a mother and a working woman.• Encourage the patient to describe her assets and deficits

as she perceives them.• Encourage the patient to list lifestyle adjustments that

need to be made.• Monitor identified possible solutions, modifications,

etc., designed to cope with each adjustment.• Teach the client relaxation skills and coping

mechanisms.

Consider the patient’s social network and significantothers:

• Identify significant others in the patient’s socialnetwork.

• Involve significant others if so desired by the patient indiscussion and problem-solving activities regardinglifestyle adjustments.

Encourage the patient to get adequate rest:• Take care of self and baby only.• Let significant others take care of the housework and

other children.• Learn to sleep when the baby sleeps.• Have specific, set times for friends or relatives to visit.• If breastfeeding, significant other can change the infant

and bring the infant to the mother at night so that themother does not always have to get up for the infant.Or the mother can sleep with the infant.

• Cook several meals at one time for the family andfreeze them for later use.

• Prepare baby formula for a 24-hour period and refriger-ate for later use.

• Freeze breast milk, emptying the breast after the babyeats; significant other can then feed the infant one timeat night so the mother can get adequate, uninterruptedsleep.

• Put breast milk into a bottle and directly into thefreezer:• Milk can be added each time breasts are pumped until

the needed amount is obtained.• Milk can be frozen for 6 weeks if needed.• To use, milk should be removed from the freezer and

allowed to thaw to room temperature.• Once thawed, must be used within a 12- to 24-hour

period. Do not refreeze.

Provides a database needed to plan changes that willincrease ability in home maintenance.

Fatigue can be a major contributor to impaired homemaintenance.

Both the parents and infant get more rest. The babybegins to nurse longer and sleep for longer periodsof time.


Home Maintenance, Impaired 363

••••••

Mental Health


Discuss with the client his or her concerns about return-ing home.

Develop with the client and significant others a list ofpotential home maintenance problems.

Teach the client and family tasks that are necessary forhome care. [NOTE tasks and teaching plan here.]

Provide time to practice home maintenance skills, at least30 minutes once a day. Medication administrationcould be evaluated with each dose by allowing theclient to administer own medications. The times andtypes of skills to be practiced should be listed here.

If financial difficulties prevent home maintenance, referto social services or a financial counselor.

If the client has not learned skills necessary to cook orclean home, arrange a time with occupational therapistto assess for ability and to teach these skills. Supportthis learning on unit by [check all that apply]:

• Having the client maintain own living area.• Having the client assist with the maintenance of the

unit (state specifically those chores the client is respon-sible for).

• Having the client assist with the planning and prepara-tion of unit meals when this is a milieu activity.

• Having the client clean and iron own clothing.

If special aids are necessary for the client to maintain selfsuccessfully, refer to social services for assistance inobtaining these items.

If the client needs periodic assistance in organizing self tomaintain home, refer to homemaker service or othercommunity agency.

If meal preparation is a problem, refer to communityagency for Meals-on-Wheels, or assist the family withpreparing several meals ahead of time or exploringnutritious, easy ways to prepare meals.

Determine with the client a list of rewards for meetingthe established goals for achievement of home mainte-nance, and then develop a schedule for the rewards.[Note the reward schedule here.]

Assess the environment for impairments to home mainte-nance, and develop with the client and family a planfor resolving these difficulties (e.g., recipes that aresimplified and written in large print to make themeasier to follow).

Provide appropriate positive verbal reinforcers for accom-plishment of goals or steps toward the goals.

Utilize group therapy once a day to provide:• Positive role models• Peer support• Realistic assessment of goals

Promotes the client’s sense of control, which enhancesself-esteem.

Promotes the client’s and support system’s sense of con-trol, which increases the willingness of the client towork on goals.

Provides opportunities for positive reinforcement ofapproximation of goal achievement.

Provides opportunities to practice new skills in a safeenvironment and to receive positive reinforcement forapproximation of goal achievement.

Positive reinforcement encourages the maintenance ofnew behavior.

Positive reinforcement encourages maintenance of newbehaviors.




••••••


Adult Health


• Exposure to a variety of problem solutions• Socialization and learning of social skills

Refer to a home health agency for continued support afterdischarge.

• Provide the client and family with contact informationfor the agency so that a relationship can be establishedbefore discharge.

This will increase the potential for community follow-upafter discharge.

Gerontic Health

Nursing actions for Adult and Home Health are appropriate for the older adult. The nurse may provide information onresources that target the elderly, such as the area Agency on Aging; local support groups for people with chronic illnesses;and city, county, or state resources for the elderly.



Monitor factors contributing to Impaired Home Main-tenance (items listed under related factors section).

Involve the patient and family in planning, implementing,and promoting reduction in the Impaired HomeMaintenance:

• Family conference• Mutual goal setting• Communication• Family members given specified tasks as appropriate

to reduce the Impaired Home Maintenance (shopping,washing clothes, disposing of garbage and trash, yardwork, washing dishes, meal preparation, etc.)

Assist the patient and family in lifestyle adjustments thatmay be required:

• Hygiene practices—obtaining assistance from familymembers, friends, or community agencies may berequired.

• Elimination of drug and alcohol use—refer the clientto sources of assistance such as Alcoholics Anony-mous, physicians who specialize in treatment of sub-stance abuse, or support groups.

• Stress management techniques – teach client stressmanagement techniques and refer as needed to commu-nity resources for stress management (support groups,therapists).

• Family and community support systems—refer theclient/family to community resources.

• Removal of hazardous environmental conditions, suchas improper storage of hazardous substances, openheaters and flames, breeding areas for mosquitoes ormice, or congested walkways.

Provides database for prevention and/or early interven-tion.




Infant Behavior, Disorganized, Risk For and Actual, and Readiness For Enhanced Organized 365

••••••


• Proper food preparation and storage—teach theclient/family safety measures for food preparation andstorage, assist client to obtain materials to facilitatesafe food handling when indicated.

Assess the client/family’s need for additional assistiveresources and refer to appropriate community agenciesas indicated.


INFANT BEHAVIOR, DISORGANIZED,RISK FOR AND ACTUAL, ANDREADINESS FOR ENHANCEDORGANIZED

DEFINITION22

Risk for Disorganized Infant Behavior Risk for alter-ation and modulation of the physiologic and behavioralsystems of functioning, that is, autonomic, motor, state,organizational, self-regulatory, and attention–interactionsystems.


Risk for Disorganized Infant Behavior (Risk Factors)

1. Invasive or painful procedures2. Lack of containment or boundaries3. Oral or motor problems4. Prematurity5. Pain6. Environmental overstimulation

DEFINITION22

Disorganized Infant Behavior Disintegrated physiologicand neurologic responses to the environment.


A. Regulatory Problems1. Inability to inhibit startle response2. Irritability

B. State-Organization System1. Active–awake (fussy, worried gaze)2. Diffuse/unclear sleep, state-oscillation3. Quiet–awake (staring, gaze aversion)4. Irritable or panicky crying

C. Attention–Interaction System1. Abnormal response to sensory stimuli (e.g., difficult

to soothe, inability to sustain alert status)D. Motor System

1. Increased, decreased, or limp tone2. Finger splay, fisting or hands to face3. Hyperextension of arms and legs4. Tremors, startles, twitches5. Jittery, jerky, uncoordinated movement6. Altered primitive reflexes

E. Physiological1. Bradycardia, tachycardia, or arrhythmias2. Pale, cyanotic, mottled, or flushed color3. Time-out signals (e.g., gaze, grasp, hiccough,

cough, sneeze, sigh, slack jaw, open mouth,tongue thrust)

4. Oximeter reading: Desaturation5. Feeding intolerances (aspiration or emesis)

RELATED FACTORS22

A. Prenatal1. Congenital or genetic disorders2. Teratogenic exposure

B. Postnatal1. Malnutrition2. Oral/motor problems3. Pain4. Feeding intolerance5. Invasive/painful procedures6. Prematurity

C. Individual1. Illness2. Immature neurologic system3. Gestational age4. Postconceptual age

D. Environmental1. Physical environment inappropriateness2. Sensory inappropriateness3. Sensory overstimulation4. Sensory deprivation

E. Caregiver1. Cue misreading2. Cue knowledge deficit3. Environmental stimulation contribution

DEFINITION22

Readiness for Enhanced Organized Infant Behavior Apattern of modulation for the physiologic and behavioralsystems of functioning, that is, autonomic, motor, state,organizational, self-regulatory, and attention–interactionsystems, in an infant that is satisfactory but that can beimproved, resulting in higher levels of integration inresponse to environmental stimuli.



••••••


1. Definite sleep–wake states2. Use of some self-regulatory behaviors3. Response to visual or auditory stimuli4. Stable physiologic measures

RELATED FACTORS22

1. Pain2. Prematurity


1. Hospitalization2. Any invasive procedure3. Prematurity

4. Neurologic disorders5. Respiratory disorders6. Cardiovascular disorders

EXPECTED OUTCOME

Will return to more organized behavioral response by [date].Will demonstrate [Note defining characteristic here]

within normal developmental limits by [date].

TARGET DATES

Disorganized infant behavior is very tiring, physically andemotionally, to both the infant and parents. Therefore, theinitial target date should be within 24 hours of the diagnosis.As the infant’s behavior becomes more organized, targetdates can be increased in increments of 72 hours.


Adult Health

For this diagnosis, the Child Health nursing actions serve as the generic actions. This diagnosis would probably not ariseon an adult health care unit.

Child Health


Monitor for all possible contributing factors related to theinfant’s status, including:

• Prenatal course• Birth history and Apgar scores• Known medical diagnoses• All genetically relevant data• Actual description of problem/triggering cues• Treatment modalities (monitors, medications, special

equipment, and/or special care related)

Determine both the mother’s and father’s (parental) per-ception of the infant’s status.

Spend [number] minutes per shift with parents discussingtheir concerns and feelings about infants status

Identify specific parameters (according to etiologic orknown cause of problem) for appropriate managementof infant; i.e., laboratory ranges (arterial blood gases)and respiratory rate, as applicable. [Note client specificplan for management of these parameters here.]

Evaluate parental capacity to assume caregiving role ofthe infant by:

• Asking the parent to verbalize special care the infantrequires

Inclusion of all contributing factors will result in an indi-vidualized plan of care.

Ultimate responsibility will be better assumed by thecaregiver if planning is long term and considersparental input.

Opportunities to express concerns and gain knowledgewill enhance coping.

Treatment of condition will be enhanced with a specific,individualized plan of care. Inclusion of early child-hood developmental specialist, occupational therapist,physical therapist, dietitian, home health nurse, andothers as required will offer essential specialized care.

Anticipatory planning will enhance likelihood of ade-quate timing and gradual relinquishment of care to theparents or, when necessary, other primary caregivers.



••••••


• Observing the parent in care behaviors while still inhospital setting for appropriateness (e.g., feeding,handling, or as necessary, giving medications, suc-tioning, etc.)

• Assessing problem-solving skills related to the infant’scare (i.e., when to call for assistance)

• Risk factor analysis of total 24-hour care of the infant• Ability to identify the infant’s cues• Ability to respond to the infant’s cues• Ability to handle, emotionally and otherwise, demands

of the infant’s status• Verbalization of expected prognosis or developmental

potential• Evidence of realistic planning for respite care backup

after discharge from hospital

Spend [number] minutes per shift discussing a plan ofcare with parents. Note status of plan development hereand update as planning progresses, noting assistanceneeded from staff to facilitate the implementation.

Provide anticipatory care, including positioning, in plan-ning for feedings, if necessary, with safety-mindednessas dictated by the infant’s status, including possibilityof cardiac or respiratory arrest.

Provide stimulation only as tolerated by the infant, toinclude minimal gentle touching, decreased sound,decreased light, decreased strong chemical odors, andgentle suctioning of oropharynx as necessary. [Notespecial adaptations for this client.]

Support the infant in basic physiologic needs as required,including:

• Dietary needs (by mouth [p.o.]), gastrostomy tube,hyperalimentation, etc.)

• Respiratory functioning or maintenance (O2, tra-cheotomy, endotracheal � ventilation � pulmonarytoileting)

• Urinary/elimination (self-toileting, diapering, Foleycatheter)

• Cardiac homeostasis (self-regulatory, medication, pace-maker, monitoring)

• Neuromuscular requisites (positioning in alignment,protection from injury in event of seizure, use ofsplints, special equipment for adaptive needs, adminis-tration of seizure medications if needed)

• Communication augmentation (close and continuousobservation, interpretation of cues, adaptive aids rang-ing from musical toys to developmentally appropriateinteractive toys)

• Tolerance of stimulation (satisfactory oxygen satura-tion, ability to rest at intervals, etc.)

Appropriate anticipation of possible cardiac or respiratoryarrest and/or related dysfunction of vital functions willbest identify degree of physiologic support required tosustain the infant.

Protection of the infant from undue environmental stres-sors during acute phase will decrease the possibility ofincreased levels or length of time when disorganizedbehavior is present.

Support of adaptive potentials may help restore patternsof organized behavior or at least maintain a moreenhanced organized behavior pattern with individual-ized allowances as a basis for determining effectivecare.




••••••


Child Health


Readiness for Enhanced Organized Infant BehaviorMonitor for all factors contributing to disorganized

behavior that can be controlled (e.g., sounds, sights,and other stimuli). Note client-specific factors here.

Develop a plan for identifying adaptation behaviors forevaluating effectiveness of current treatment and redef-inition.

Once enhancement behaviors are identified, redefine planof care to best incorporate client goals.

• Spiritual Distress, Risk For• Anticipatory Grieving• Parent, Infant, Child Attachment, Impaired, Risk for

Also, it could be that this infant requires long-term carewith allowance for acute exacerbations made worse byunderlying disorganized infant behavior.

Inclusion of all contributing factors will most likely offerpotential to influence the infant’s behavior on an indi-vidualized basis.

Ongoing evaluation will serve the purpose of substantia-tion of progress and thereby define enhancementbehaviors and patterns.

● N O T E : Case management becomes an issue of paramount importance with a needto keep the family updated as changes occur. Also, in event of compromise and/orultimate death, there should be consideration for:

Women’s Health

● N O T E : This diagnosis will relate to the delivery room and the immediate postpartumperiod (48 to 72 hours). For further clarification beyond this period, see Child Health.


Monitor the infant’s cardiovascular and respiratory systemby use of Apgar score, at 1 and 5 minutes after birth.

Prepare for neonatal resuscitation by having all equip-ment and supplies ready. Be prepared to supportneonatal staff, if available, and/or pediatrician. Supportand reassure the parents by keeping them informed ofthe infant’s condition.

Support the parents of the ill neonate by being availableto listen and answer questions.

Act as a liaison between neonatal intensive care unit(NICU) and the parents, assisting both parties byclarifying and explaining.

Apgar score is an indicator of the infant’s condition atbirth and provides a baseline for determining the needfor appropriate interventions and neonatal resuscitation.

If there is a compromised infant, then it is appropriatefor the nurse in the delivery room to support and assistthe neonatal staff in stabilizing the infant. If no neona-tal staff is available, the labor–delivery staff needsto be well versed in neonatal stabilization and resusci-tation.

Parents often need to verbalize what they have been toldby the neonatologist and the NICU staff. This helpsthem cope and can provide clarification of any infor-mation they have been given. The nurse who listenscan correct inaccurate perceptions and keep NICUstaff informed of the parents’ understanding so theycan better understand and provide support where themother and family are physically and emotionallystressed.



••••••

Accompany and/or transport the patient to NICU the firsttime, to provide guidance and support, as well as intro-ducing him or her to the NICU staff.

If the infant is transported to another hospital, keep themother informed by establishing contact with theNICU staff.

Obtain pictures of the infant and telephone numbers sothe mother can call and talk with NICU staff.

Monitor and document the infant’s physiologic parame-ters during periods of reactivity:

• Assist new parents in utilizing the normal periods ofreactivity in the neonate to begin breastfeeding and theparent–infant attachment process.

• Perform a complete physical assessment of the new-born, documenting findings in an organized manner(usually head to toe).

• Note and inform the parents of aspects of normal new-born appearance, especially noting such items as milia,normal newborn rash, or “stork bites.”

• Explain the importance of thermoregulation, voidingpatterns, and neurologic adaptations during the imme-diate newborn period.

• Practice good handwashing techniques before touchingthe newborn, and explain to the parents the importanceof this in preventing infection.

• Monitor the infant for ability to feed (breast or bottle),intake, output, and weight loss or gain.

• Encourage parent participation in the care and observa-tion of the infant.

• Be available to answer questions and demonstrate tech-niques of baby care to new parents.

Prevent heat loss by immediately drying the infant andlaying him or her on a warmed surface (best place isskin-to-skin with the mother).

Immediate Postpartum PeriodPerform a gestational age assessment, and compare the

infant’s gestational age and weight. Based upon thisexamination, determine whether infant is83:

• Average for gestational age (AGA)• Small for gestational age (SGA)• Large for gestational age (LGA)

Review the mother’s prenatal and labor–deliveryhistories for factors that would interfere with thenormal transitional physiologic process by theneonate, such as metabolic disorders (diabetes, etc.)and/or use of medications, both therapeutic andabusive.

Continue to monitor the infant’s vital signs frequently.

Utilizing every opportunity to teach new parents abouttheir newborn increases confidence and infant caretak-ing activities.

Drying decreases the incidence of iatrogenic hypothermiain the newborn. (Infant’s temperature can drop as muchas 4.7�F in the delivery room.)82

Gestational age and the size (AGA, SGA, LGA) of theinfant can affect the transition to extrauterine life.

The use of drugs during labor or prenatally, and maternaldiseases such as diabetes may inhibit the thermoregula-tory and cardiovascular responses or respiratoryeffort.83





••••••

Gerontic Health

This diagnosis would probably not be used in Gerontic Health.


Mental Health

● N O T E : Mental health interventions for this diagnosis would focus on family support.Refer to the following diagnoses for care plans:

Management of Therapeutic Regimen (Family), IneffectiveCaregiver Role StrainFamily Coping, Compromised or DisabledFamily Coping, Readiness for Enhanced

Parenting, Impaired or Risk forThe practitioner should review the definition and defining characteristics of these diag-noses to determine which one relates to those characteristics being demonstrated by theinfant’s family and/or support system.

Home Health


Assist the client and family in lifestyle changes that maybe required. Provide for:

• Supportive environment• Consistent care provider• Appropriate stimulation• Control of pain—teach the caregiver to recognize signs

of pain, and appropriate pain management actions, toinclude safe use of prescribed analgesics.

• Understanding of normal growth and development—teach the caregiver normal developmental milestonesand their associated behaviors.

Assist the family to set criteria to help them determinewhen additional intervention is required (e.g., changein baseline physiologic measures).

Assess the client/caregiver need for assistive resourcesand refer to appropriate community agencies.

Home-based care requires involvement of the family.Disorganized infant behavior can disrupt family sched-ules. Adjustment in family activities may be required.

Provides the family with background knowledge to seekappropriate assistance as need arises.

Additional assistance may be required for the family tocare for the infant. Use of readily available resources iscost effective.

PERIPHERAL NEUROVASCULARDYSFUNCTION, RISK FOR

DEFINITION22

A state in which an individual is at risk of experiencing a dis-ruption in circulation, sensation, or motion of an extremity.


1. Trauma2. Vascular obstruction

3. Orthopedic surgery4. Fractures5. Burns6. Mechanical compression, for example, tourniquet, cast,

brace, dressing, or restraint7. Immobilization

RELATED FACTORS22

The risk factors also serve as the related factors for this riskdiagnosis.


Peripheral Neurovascular Dysfunction, Risk For 371

••••••


1. Fractures2. Buerger’s disease3. Thrombophlebitis4. Burns5. Cerebrovascular accident


Ineffective Tissue PerfusionIneffective Tissue Perfusion is an actual diagnosis andindicates that a definite problem has developed. Riskfor Peripheral Neurovascular Dysfunction indicates

that the patient is in danger of developing a problemif appropriate nursing measures are not instituted tooffset the problem development.

EXPECTED OUTCOME

Will develop no problems with peripheral neurovascularfunction by [date].

TARGET DATES

Initial target dates should be stated in hours. After the patientis able to be more involved in self-care and prevention, thetarget date can be expressed in increments of 3 to 5 days.


Adult Health


Assess skin integrity, especially areas affected by devicesthat may affect peripheral neurovascular function (e.g.,restraints, traction, or casts) every 2 hours on[odd/even] hour.

Perform color, movement, sensation (CMS) checks topotential trouble areas (e.g., circumferential burns,cardiac catheterization, fractures) at least every 2hours.

Assist the patient with ROM exercise every 2 hours on[odd/even] hour.

Instruct the patient regarding isometric and isotonicexercises. Have the patient exercise every 4 hourswhile awake at [times].

Keep extremities warm.

Turn every 2 hours on [odd/even] hour.

Monitor the patient’s understanding of the effects ofsmoking, or if nonsmoker, the effects of passivesmoke on peripheral circulation.

Refer to physical therapy as necessary.

Allows intervention before skin breakdown occurs.

Increases circulation and maintains muscle tone andmovement.

Promotes circulation.

Prevents sustained pressure on any pressure point.

Smoking constricts peripheral circulation, leading toincreased problems with peripheral neurologic andvascular functioning.

Child Health


Determine exact parameters to be used in monitoring riskconcerns (e.g., if the patient is without sensation inspecific levels of anatomy, document what the knowndeficits are: High level of myelomeningocele, lumbar4, with apparent sensation in peroneal site). [Noteclient specific adaptations here.]

Specific parameters for assessment of neurodeficits canguide caregivers in choosing the best precautionarytreatment.49




••••••


Child Health


Carry out treatments with attention to the neurologicdeficits (e.g., using warm pads for a child unable toperceive heat would require constant attention for signsor symptoms of burns).

Provide teaching according to the patient and familyneeds, especially with regard to safety. [Note clientspecific teaching plan here.]

Include the family in care and use of equipment (e.g.,braces, etc.).

Refer to appropriate community agencies for follow-up.49

Teach the patient (as developmentally appropriate) andfamily administration of medications especially antico-agulation agents as low-dose heparin.49

Common safety measure.

Appropriate assessment will best foster learning and helpprevent injury.49

Family involvement assuages the child’s emotional needsand empowers the parents.

Long-term follow-up validates the need for recheckingand offers a time to reassess progress in goal attain-ment or altered patterns.

Provides anticipatory guidance in safe administrationof medications.49

Women’s Health

● N O T E : Women are at risk for thrombosis in the lower extremities during pregnancyand the early postpartum period. Because of decreased venous return from the legs,compression of large vessels supplying the legs during pregnancy, and during pushingin the second stage of labor, patients need to be continuously assessed for this prob-lem.84


Closely monitor the patient at each visit and teach patientto self-monitor size, shape, symmetry, color, edema,and varicosities in the legs.

Encourage the patient to walk daily during the pregnancyand to wear supportive hosiery.

Assist the patient to plan a day’s schedule during preg-nancy that will allow her time to rest. The scheduleshould also include several times during the day for herto elevate her legs.

Encourage the patient to use a small stool when sitting(e.g., at desk to keep feet elevated and less compres-sion on upper thighs and knees).

In the event thrombophlebitis develops:• Monitor legs for stiffness, pain, paleness, and swelling

in the calf or thigh every 4 hours around the clock.• Place the patient on strict bedrest with the affected leg

elevated.

Provide analgesics as ordered for pain relief, and assessfor effectiveness within 30 minutes of administration.

Place a bed cradle on the bed.

Knowledge of the problem and its causative factors canassist in planning and carrying out good health habitsduring pregnancy. This knowledge can assist in pre-venting thrombotic complications during pregnancy.

Basic assessment for early detection of complications.

Basic safety measure to avoid dislodging of clots.

Keeps pressure of bed linens off the affected leg.


Physical Mobility, Impaired 373

••••••


Administer and monitor the effects of anticoagulant ther-apy as ordered. Collaborate with the physician regard-ing the frequency of laboratory examinations tomonitor clotting factors.

● N O T E : Breastfeeding mothers who are taking heparin can continue to breastfeed.Breastfeeding mothers who are taking dicumarol should stop breastfeeding, because itis passed to the infant in breast milk.

Do not rub, massage, or bump affected leg. Handle withcare when changing linens or giving bath.

Assist the family to plan for care of the infant; includethe mother in planning process.

Encourage verbalizations of fears and discouragementby the mother and family.

Basic safety measures to avoid dislodging clots.

Assist the patient and family in coping with illness.Promotes effective implementation of home care.Provides support and teaching opportunity.

Mental Health

The mental health client with this diagnosis requires the same type of nursing care as the adult client. A review of thenursing actions for Activity Intolerance, Impaired Physical Mobility, and Ineffective Tissue Perfusion would also be ofassistance.

Gerontic Health


Avoid the use of restraints if at all possible.

Monitor restraints, if used, at least every 2 hours on[odd/even] hour. Release restraints, and perform ROMexercises before reapplying.

Restraint use in older adults can lead to physical andmental deterioration, injury, and death.85

Frequent monitoring decreases the injury risk.

Home Health

Nursing actions for the home health client with this diagnosis are the same as those for the Adult Health client.

PHYSICAL MOBILITY, IMPAIRED

DEFINITION22

A limitation in independent purposeful physical movementof the body on one or more extremities


1. Postural instability during performance of routine activi-ties of daily living

2. Limited ability to perform gross motor skills3. Limited ability to perform fine motor skills4. Uncoordinated or jerky movements5. Limited range of motion6. Difficulty turning

7. Decreased reaction time8. Movement-induced shortness of breath9. Gait changes (e.g., decreased walk-spread, difficulty

initiating gait, small steps, shuffles feet, exaggeratedlateral position sway)

10. Engages in substitutions for movement (e.g., increasedattention to other’s activity, controlling behavior, focuson pre-illness or disability activity)

11. Slowed movement12. Movement-induced trauma

RELATED FACTORS22

1. Medications2. Prescribed movement restrictions3. Discomfort



••••••

4. Lack of knowledge regarding value of physical activity5. Body mass index above 75th age-appropriate percentile6. Sensoriperceptual impairments7. Neuromuscular impairment8. Pain9. Musculoskeletal impairment

10. Intolerance to activity or decreased strength andendurance

11. Depressive mood state or anxiety12. Cognitive impairment13. Decreased muscle strength, control, and/or mass14. Reluctance to initiate movement15. Sedentary lifestyle, or disuse or deconditioning16. Selective or generalized malnutrition17. Loss of integrity of bone structure18. Developmental delay19. Joint stiffness or contracture20. Limited cardiovascular endurance21. Altered cellular metabolism22. Lack of physical or social environmental supports23. Cultural beliefs regarding age-appropriate activities


1. Fractures that require casting or traction2. Rheumatoid arthritis3. Cerebrovascular accident4. Depression5. Any neuromuscular disorder


Activity IntoleranceThis diagnosis implies that the individual is freely ableto move but cannot endure or adapt to the increasedenergy or oxygen demands made by the movement oractivity. Impaired Physical Mobility indicates that anindividual would be able to move independently ifsomething were not limiting the motion.

Impaired Physical MobilityThis diagnosis also needs to be differentiated from therespiratory (Impaired Gas Exchange and IneffectiveBreathing Pattern) and cardiovascular (Decreased

Cardiac Output and Ineffective Tissue Perfusion) nurs-ing diagnoses. Mobility depends on effective breathingpatterns and effective gas exchange between thelungs and the arterial blood supply. Muscles have toreceive oxygen and get rid of carbon dioxide for con-traction and relaxation. Because oxygen is transportedand dispersed to the muscle tissue via the cardiovas-cular system, it is only logical that the respiratory andcardiovascular diagnoses could impact mobility.

Imbalanced Nutrition, More or LessThan Body RequirementsNutritional deficit would indicate that the body is notreceiving enough nutrients for its metabolic needs.Without adequate nutrition, the muscles cannot func-tion appropriately. With More Than BodyRequirements, mobility may be impaired simplybecause of the excess weight. In someone who isgrossly obese, range of motion is limited, gait isaltered, and coordination and tone are greatly reduced.

EXPECTED OUTCOME

Will verbalize plan to increase strength and endurance by[date].

Will demonstrate ability to [note target mobilitybehavior here] with assistance by [date].

Will demonstrate ability to [note target mobilitybehavior here] unaided by [date].

TARGET DATES

These dates may be short term or long term, based on theetiology of the diagnosis. An acceptable first target datewould be 5 days.

*Suggested Functional Level Classification0 � Completely independent1 � Requires use of equipment or device2 � Requires help from another person, for assis-

tance, supervision, or teaching3 � Requires help from another person and equip-

ment service4 � Dependent, does not participate in activity(Code adapted by NANDA.) 106


Adult Health


Educate the patient regarding proper use of assistivedevices

Provide progressive mobilization as tolerated. Scheduleincreased mobilization on a daily basis.

Maintains muscle tone and prevents complications ofimmobility.



••••••


Medicate for pain as needed, especially before activity.Exercise caution with medications that effect senso-rium.

Perform ROM exercises (passive, active, and functional)every 2 hours on [odd/even] hour.

Maintain proper body alignment at all times; supportextremities with pillows, blankets, towel rolls, or sand-bags.

Implement measures to prevent falls, such as keeping bedin low position, wearing appropriately fitting shoes ornonskid slippers.

Devise strategies for strength training.

Maintain adequate nutrition.

Observe for complications of immobility (e.g., constipa-tion, muscle atrophy, decubitus ulcers).

Include the patient and family or significant other in car-rying out plan of care.

Initiate physical therapy and/or occupational therapy assoon as feasible.

Pain interferes with ability to ambulate by inhibiting mus-cle movement.

Increases circulation, maintains muscle tone, and preventsjoint contractures.

Prevents flexion contractures and progression of compli-cations.


Provides nutrients for energy, and prevents protein lossdue to immobility.

Allows early detection and prevention of complications.

Allows time for practice under supervision. Increaseslikelihood of effective management of therapeuticregimen.

Child Health


Monitor alteration in mobility each 8-hour shift accordingto:

• Actual movement noted and tolerance for the move-ment

• Factors related to movement (e.g., braces used,progress in use)

• Situational factors (e.g., previous status, current healthneeds, or movement permitted)

• Pain• Circulation check to affected limb• Change in appearance of affected limb or joint

Include related health team members in care of thepatient as needed. [Note plan for their involvementhere.]

Consider patient and family preferences in planning tomeet desired mobility goals. [Note special adaptationsneeded to incorporate family/patient preferenceshere.]49

Facilitate participation of family members, especially theparents, in care of the patient according to needs andsituation (feeding, comfort measures). [Notepatient/family specific adaptations here.]

Provides the primary database for an individualized planof care.

The nurse is in the prime position to coordinate healthteam members to best match needs and resources.

Consideration of preferences increases likelihood of plansuccess.

Involving the family in care serves to enhance their skillsin care required at home.




••••••

Women’s Health

● N O T E : The following nursing actions apply to those women placed on restrictiveactivities because of threatened abortions, premature labor, multiple pregnancy, orpregnancy-induced hypertension.


Facilitate the participation of the family and significantothers in the plan of care for the patient.

When resting in bed, have the patient rest in the left lat-eral position as much as possible.

Encourage the patient to list lifestyle adjustments thatwill need to be made.

Teach the patient relaxation skills and coping mecha-nisms.

Facilitate adequate protein intake. [Note special needshere.]

Maintain proper body alignment with use of positioningand pillow.

Provide diversionary activities (e.g., hobbies, job-relatedactivities that can be done in bed, or activities withchildren).

Facilitate help and visits from friends and relatives:• Visit in person• Telephone visit• Help with child care• Help with housework

Prevents supine hypotension, and allows adequate renaland uterine perfusion.

Decreases anxiety and muscle tension.

Replaces protein lost because of decreasing muscle con-traction during immobility.

Decreases anxiety and reduces muscle tension. Providesappropriate amounts of activity without danger topregnancy.


Child Health


Provide diversional activities appropriate for age anddevelopmental level. [Note those activities preferred byclient here.]

Maintain appropriate safety guidelines according to ageand developmental guidelines.

Monitor traction or related equipment in use (e.g.,weights hanging free or rope knots tight).

Monitor patient and family needs for education regardingthe patient’s situation and any future implications.[Note plan for family education here.]

Monitor intake and output to ensure adequate fluid bal-ance for each 24-hour period.

Address related health issues appropriate for the patientand family.

Diversional activity, when appropriately planned, servesto refresh and relax the patient

Basic requirements for maintaining standards of care.

Ensures therapeutic effectiveness of equipment, and pro-vides for safety issues related to these interventions.

Allows timely planning for home care, and allows prac-tice of care in a supportive environment.

Strict intake and output will assist in monitoring hydra-tion status, which is crucial for healing and circulatoryadequacy.

Appropriate attention to related health issues fostersholistic care (e.g., the child may need braces, but mayalso have need for healing, or speech followup second-ary to meningitis, and developmental delays).49



••••••

Mental Health


Attempt all other interventions before considering immo-bilizing the client as an intervention. (See Risk forViolence, Chapter 9, for appropriate nursing actions.)

Carefully monitor the client for appropriate level ofrestraint necessary. Immobilize the client as little aspossible while still protecting the client and others.

Obtain necessary medical orders to initiate methods thatlimit the client’s physical mobility.

Carefully explain to the client in brief, concise languagereasons for initiating this intervention, and what behav-ior must be present for the intervention to be termi-nated.

Attempt to gain the client’s voluntary compliance withthe intervention by explaining to the client what isneeded and with a “show of force” (have the necessarynumber of staff available to force compliance).

Initiate forced compliance only if there is an adequatenumber of staff to complete the action safely. (SeeRisk for Violence, Chapter 9, for a detailed descriptionof intervention with forced compliance.)

Secure the environment the client will be in by removingharmful objects such as accessible light bulbs, sharpobjects, glass objects, tight clothing, and metal objectssuch as clothes hangers or shower curtain rods.

If the client is placed in four-point restraints, maintainone-to-one supervision.

If the client is in seclusion or bilateral restraints, observethe client at least every 15 minutes, more frequently ifagitated [List observation schedule here.]

Leave the urinal in room with the client, or offer toiletingevery hour.

Offer the client fluids every 15 minutes.

Discuss with the client his or her feelings about the initia-tion of immobility, and review with him or her again,at least twice a day, the behavior necessary to haveimmobility discontinued.

When checking the client, let him or her know you arechecking by calling him or her by name and orientinghim or her to day and time. Inquire about the client’sfeelings, and implement necessary reality orientation.

Provide meals at regular intervals on paper containers,providing necessary assistance. [Amount and type ofassistance required should be listed here.]

Promotes the client’s sense of control and supports self-esteem.

Excessive stimuli can increase confusion. Provides theclient with sense of control.

Promotes the client’s sense of control and safety, whichpromotes self-esteem.

Client and staff safety are of primary concern.

Prevents injury by protecting the client from impulsiveactions of self-harm.

Client safety is primary concern.

Maintains adequate hydration.

Exploration of feelings in an accepting environment helpsthe client identify and explore maladaptive copingbehaviors. Promotes the client’s sense of perceivedcontrol.

Promotes perceived control and promotes an environmentof trust.

Meets biophysical needs while providing consistency in arespectful manner, which promotes self-esteem andtrust.

● N O T E : The following actions and interventions are related to imposed restrictions.This includes seclusion and restraint.




••••••


Mental Health


If the client is in restraints, remove restraints at leastevery 2 hours, one limb at a time. Have the client movelimb through a full ROM and inspect for signs ofinjury. Apply lubricants such as lotion to area underrestraint to protect from injury.

Pad the area of the restraint that is next to the skin withsheepskin or other nonirritating material.

Check circulation in restrained limbs in the area belowthe restraint by observing skin color, warmth, andswelling. Restraint should not interfere with circulation.

Change the client’s position in the bed every 2 hours on[odd/even] hour.

Place body in proper alignment. Use pillows for supportif the client’s condition allows.

If the client is in four-point restraints, place him or her onstomach or side.

Place the client on intake and output monitoring.

Have the client in seclusion move around the room atleast every 2 hours on [odd/even] hour, and during thistime initiate active ROM.

Administer medications as ordered for agitation.

Monitor blood pressure before administering antipsy-chotic medications.

Assist the client with daily personal hygiene (record timefor this here).

Have environment cleaned on a daily basis.

Review with the client the purpose for restraint or seclu-sion as required, and discuss alternative kinds ofbehavior that will express feelings without threateningself or others.

Remove the client from seclusion as soon as the con-tracted behavior is observed for the required amount oftime (both of these should be very specific and listedhere). (See Risk for Violence, Chapter 9, for detailedinformation on behavior change and contractingspecifics.)

Schedule time to discuss this intervention with the clientand his or her support system. Inform support systemof the need for the intervention and about special con-siderations related to visiting with the client. Thisinformation must be provided with consideration ofclient confidentiality. Plan to spend at least 5 minuteswith the members of the support system before andafter each visit.

Promotes normal circulation and motion, which preventsinjury to the limb.

Protects skin from mechanical irritation.

Early assessment and intervention prevents serious injury.

Prevents disuse syndrome.

Prevents complications and injury.

Prevents aspiration or choking.

Ensures that adequate fluid balance is maintained.

Prevents complications of immobility.

Medications reduce anxiety and facilitate interaction withothers.

Psychotropic medications can cause orthostatic hypoten-sion.

Communicates positive regard for the client by the nurse,which facilitates the development of positive self-esteem.

Promotes sanitary conditions and provides an orderlyenvironment, which can decrease the client’s disorgani-zation and confusion.

Promotes the client’s sense of control by providing himor her with behavioral alternatives and establishingclear limits.

Provides positive reinforcement for appropriate copingbehavior, and promotes the client’s sense of control.

Support system understanding and support of treatmentgoals has a positive effect on client outcome.



••••••


Arrange consultations with appropriate resources after theclient is released from mobility limitations to assist theclient with developing alternative coping behavior. Thiscould include a physical therapist, an occupationaltherapist, or a social worker.

• If restrictions are due to anxiety, refer to Chapter 8 andthe diagnosis of Anxiety.

• If restrictions are due to depressed mood, implementthe following interventions:• Sit with the client for [number] minutes [number]

times per shift. Initially these times will be brief butfrequent (e.g., 5 minutes per hour).

• Establish clear expectations for these interactions(e.g., the client is not expected to talk, it is okay forthese times to be spent in silence).

Explain to the client in simple concrete terms the positiveeffects of physical activity on mood. [Note personresponsible for this teaching here.]

Talk with the client about activities they have enjoyed inthe past.

Develop with the client a program for increasing physicalactivity. Note that contact here. Also note rewards foraccomplishing goals (e.g., will walk from bed to dooronce per hour). If accomplished, the client can remainin bed during visiting hours. Activities can increase asthe client masters each step.

Provide positive verbal reinforcement for accomplishingtasks.

Recognize the client’s perceptions about the difficulty ofphysical activity in the initial stages of recovery.

Pair physical activity with situations the client findsrewarding. Note these situations here (e.g., walkingwith the client to get a cup of coffee. This pairs walk-ing with two things the client finds rewarding: timewith the nurse and coffee).

Have the client identify perceived barriers to increasedphysical activity. Note those here and developwith the client plan for reducing these. [Note planhere.]

Teach support system importance of the client’s increas-ing physical activity, and have them identify waysthey could assist with this. Note here the personresponsible for this, and record the plan when it isdeveloped.

Facilitates the development of trust as well as respect forthe client, which can have a positive effect on theclient’s self-esteem.

Communicates respect for the client, and facilitates theclient’s perception of control.

Physical activity can stimulate endorphin production,which has a positive effect on mood.

Promotes a positive expectational set based on past posi-tive experiences.

Promotes the client’s sense of control. Positive reinforce-ment encourages behavior and enhances self-esteem.

Positive recognition from significant others enhancesself-esteem.

Communicates acceptance of the client, and facilitates thedevelopment of a trusting relationship.

Promotes positive expectational set by pairing physicalexercise with a positive stimulus.

Promotes the client’s sense of control and increases theclient’s commitment to the plan because he or she hascontributed to the plan.

Support system involvement increases the probability forpositive outcome.

● N O T E : The following interventions are related to restrictions due to psychogeniccauses.




••••••

Home Health


Assist the patient and family in identifying risk factorspertinent to the situation:

• Immobility• Malnourishment• Confusion or lethargy• Physical barriers• Neuromuscular deficit• Musculoskeletal deficit• Trauma• Pain• Medications that affect coordination and level of

arousal• Debilitating disease (cancer, stroke, diabetes, muscular

dystrophy, multiple sclerosis, arthritis, etc.)• Depression• Lack of or improper use of assistive devices• Casts, slings, traction, IVs, etc.• Weather hazards



Gerontic Health


A C T I O N S / I N T E R V E N T I O N S R AT I O N A L E SMonitor for complications of immobility such as:• Orthostatic hypotension• Thrombosis• Urinary tract infections• Constipation

Assess the client for depression and treat appropriately.

Observe the patient for Valsalva maneuver (increasedintrathoracic pressure induced by forceful exhalationagainst a closed glottis) when he or she is changingposition, pushing a wheelchair, or toileting.

Monitor for behavioral changes that may result fromdecreased sensory stimulation or decreased socializa-tion (e.g., depression, hostility, confusion, or anxiety).

Observe when increasing mobility, transferring, or duringearly ambulation stage for the risk for falls.

Teach the client to perform isometric muscle contraction(i.e., tightening of muscle group as hard as possibleand then relaxing the muscle).

Collaborate with health-care team to provide supervisedflexibility and range of motion exercises for client.

Normal aging changes in combination with immobilitycan leave the older adult at increased risk for com-plications.86

Depression can contribute to sedentary lifestyle andresulting immobility.

Valsalva maneuver can produce increased pulse rate andincreased blood pressure. This adversely affectspatients with cardiovascular disorders, which maylead to their choosing not to engage in physicalactivity.86

Psychological changes not addressed may increase prob-lems of physical mobility and lead to prolonged peri-ods of immobility.

Older adults may be at risk for falls secondary to ortho-static blood pressure changes or problems with bal-ance, especially after prolonged periods of immobility.

Isometric contraction helps maintain muscle strength,which can decrease with immobility as much as 5 per-cent per day.86

Maintain muscle strength.


Sedentary Lifestyle 381

••••••


Teach the client and family measures to promote physicalactivity:

• Use of assistive devices (wheelchairs, crutches, canes,walkers, prostheses, adaptive eating utensils, devices toassist with activities of daily living, etc.)

• Providing safe environment (reducing barriers to activ-ity such as throw rugs, furniture in pathway, electriccords on floor, doors, or steps)

• Maintaining skin integrity• Use of safety devices (ramps, lift bars, tub rails, tub or

shower seat)• Proper transfer techniques

Assist the patient and family in identifying lifestylechanges that may be required:

• Alteration in living space (ramps, assistive devices,etc.)

• Changes in role functions• Range of motion exercises• Positioning and transferring techniques• Pain control• Progressive activity• Use of assistive devices• Prevention of injury• Maintenance of skin integrity• Assistance with activities of daily living• Special transportation needs• Financial concerns

Assess the client/family need for assistance with obtain-ing assistive devices, or in home assistance with ADLs,cooking, and housework. Refer to community agenciesproviding needed services.



SEDENTARY LIFESTYLE

DEFINITION22

Reports a habit of life that is characterized by a low physi-cal activity level.


1. Chooses a daily routine lacking physical exercise.2. Demonstrates physical deconditioning.3. Verbalizes preference for activities low in physical

activity.

RELATED FACTORS22

1. The risk factors also serve as the related factors for thisdiagnosis.

2. Deficient knowledge of health benefits of physical exer-cise

3. Lack of training for accomplishment of physical exercise

4. Lack of resources (time, money, companionship, facil-ities)

5. Lack of motivation6. Lack of interest

EXPECTED OUTCOME

Will participate in increased physical activity by [date].(Specify which activity: walking, swimming, chair exercises,and the frequency, duration, or intensity of the activity.)

E X A M P L E

Will increase walking by at least one block each weekfor 8 weeks.

TARGET DATES

Appropriate target dates will have to be individualizedaccording to the degree of deconditioning. An appropriaterange would be 3 to 5 days.



••••••


Adult Health


Collaborate with primary care provider to ensure thatpatient has no medical conditions precluding the initia-tion of an exercise plan.

Engage the patient in a dialogue to determine perceptionof barriers and patient preferred activities that wouldpromote lifestyle change

Provide teaching to convey pertinent benefits that wouldenhance patient’s health status. [Note specific teachingplan for this client here.]

Collaborate with the patient to establish realistic goals forincreasing activity. Note client goals here.

Discuss simple methods that do not involve financialinvestment: walking in the neighborhood, parking carfarther from destination, taking stairs, and moderateyard work.

Advise patient regarding safety precautions (e.g., startingin moderation and not in extreme temperatures).

Underscore the importance of gradual introduction intoexercise routine. Teach the patient about indicators ofoverexertion: shortness of breath, chest pain, and dizzi-ness.

Have the patient maintain weekly journal of activityincluding type, frequency, and response.

Collaborate with patient and physical therapy or rehabili-tation specialist to devise appropriate program withincreasing intensity.

Ensures that physical activity will be initiated safely.

Change is dependent on patient’s perception of the prob-lem.

Gives the patient a rationale for lifestyle change.

Conveys to patient that finances are not a realistic barrierto exercise and provide easy access with minimal life-style change.

Promotes safety.

Provides tangible feedback to the patient and tracksprogress and need for change.

Promotes sense of ownership in program.

Child Health


Monitor for contributing factors, especially current med-ical status and potential limitations imposed.

Develop, with the client and family, specific goals foractivity.

Identify strategies to attain the goal.

Involve other health team members as appropriate,including pediatrician, pediatric cardiologist, or otherprimary care provider, nutritionist, occupational orphysical therapist, and child life specialist.

Establish need for supervision and equipment essential inevent of untoward response to exercise or activity*May include halter monitoring or peak flow meterassessment.

Determine a mutually satisfactory way to reward thechild for participation. [Note that plan here.]

Provides a realistic basis for plan of care.

Creates a measurable goal.

Provides a realistic plan.

Offers safe and appropriate plan to match the child’spotential.

Provides anticipatory planning in the event of an unto-ward response during activity.

Satisfies reinforcement with likelihood for continued suc-cess with plan.



••••••


Discuss with child and family values related to increasedactivity vs. rationale for not remaining sedentary.

Develop peer activities mutually agreed upon by childand parents to assist in support of desired activities.

Allows for likelihood of exploring lifelong values toassist in maintenance of health.

Allows for child’s input within parental framework toconsider peer interaction with resultant likelihood tocontinue activity.

Women’s Health

● N O T E : Women’s lifestyles will be the same as for Adult Health with the followingnotations:


Living—A Five-Step Program (American College ofSports Medicine: 1998);

1. Get moving, quantity of cardiovascular exercise2. Get in the zone–quality of cardiovascular exercise3. Strength Training Assessment (excellent to prevent

bone loss)4. Nutrition and Exercise104

Assist the client to plan, start, and maintain an exerciseprogram that fits their life-stage. Be certain that whenplanning an exercise program, you (1) consider thewoman’s experiences, (2) make no assumptions basedon popular literature, and (3) look at what is meaning-ful interaction for the woman.104

Poverty remains one of the major factors affectingwomen’s health. Sixty percent of chronic diseases arepreventable, and exercise is becoming known as havingthe greatest benefit to prevent chronic diseases.

Biological changes in cardiovascular, respiratory, andmusculoskeletal systems plus inactivity place womenat risk for disability.88

Statistics show that 55% of American adults have beenclassified as obese, and 58 million Americans are diag-nosed as “clinically obese.” This factor, along withstress and a sedentary lifestyle is leading to millions ofAmericans becoming progressively disabled, losingtheir ability to perform such basic functions as gettingin and out of a car or chair.104

Women go through five stages of change as they adopt anexercise regimen: (1) precontemplation, (2) contempla-tion, (3) preparation, (4) action, and (5) maintenance.When most women reach the maintenance stage andexercise has become a routine part of their life, theyfeel a sense of empowerment and well-being.104

Lifestyle choices such as nutritious diet, regular exercise,and avoidance of smoking will help prevent the major-ity of chronic diseases.87

Researchers report that 30 to 60 percent of the generalpopulation does not do any physical activity, and 42percent of those who are 65 and older state they leadsedentary lives.88

Mental Health


Spend [number] minutes discussing with client his or herperception of lifestyle and experiences with increasedactivity and exercise. Identify what he or she thinks ismost important about the current situation.

Determine the client’s current physical abilities. This canbe done in collaboration with his or her primary careprovider.

Provide feedback to the client about discrepancies in cur-rent behavior and stated values/goals.

Provide the client with arguments for and against change.

Helps determine aspects of the client’s cognitive appraisalthat could impact learning.34

Presents an opportunity to review with the client howbehavior change will facilitate goal achievement.89

If the client is resistant to change, this places the nurse ina neutral position and prevents the client pushing backin non-growth-promoting directions.89




••••••

Gerontic Health


Monitor current potential for activities, including:• Activities of interest• Physical limitations• Realistic expectations for goal achievement• Objective criteria by which specific progress may be

measured (e.g., distance, time)• Previous activities the patient enjoyed

Assess community resources for exercise (e.g., walkingtracks, indoor pools, and church activity centers) andrefer the client to facilities that are nearby or thatmatch the client’s interests.

Teach client about various ways to increase activity:• Walking• Graduated Walking• Bicycling• Swimming

Include education about safety with each type of activity.

Teach the client safety measures to consider whenincreasing activity:

• Always check with a physician before starting an exer-cise program.

• Stop and consult a health-care professional if pain orunusual symptoms occur (e.g., chest pain, palpitations,irregular heart beat, dizziness, light headedness, nau-sea, vomiting, extreme fatigue, pale or splotchy skin,“cold sweat”)

Provides baseline for planning activities and increase inactivities.

Assists the client in utilizing existing resources.

Assists the client in making informed decisions.

Promotes safety.


Mental Health


Contribute positive outcomes and successes to the client.• Use these successes to demonstrate to the client that he

or she has the resources to change their behavior.

Include the client in decisions about change and progresstoward changes.

Develop, with the client, a specific plan for change. [Notethat plan here and the support needed from staff toimplement the plan.]

Provide positive, informative verbal reinforcement forgoal attainment.

Develop, with the client, a specific plan for maintainingthese changes after discharge.

• Provide the client with a written plan to take with himor her.

Promotes self-efficacy. Builds confidence in ability tochange.89

Promotes self-efficacy.89

Positive reinforcement promotes behavior change.34



••••••


• Start in small increments and increase as tolerated• Avoid exercising for 2 hours after a large meal and

do not eat for 1 hour after exercising.• Include warmup and cool down exercises.• Use proper equipment and clothing• Wear comfortable rubber soled shoes and loose

clothing.• Avoid exercising in extreme heat or cold.90



Monitor current potential for activities, including:• Activities of interest• Physical limitations• Realistic expectations for goal achievement• Objective criteria by which specific progress may be

measured (e.g., distance, time)• Previous activities the patient enjoyed

Assess community resources for exercise (e.g., walkingtracks, indoor pools, and church activity centers) andrefer the client to facilities that are nearby or thatmatch the client’s interests.

Teach the client about various ways to increase activity:• Walking• Graduated Walking• Bicycling• Swimming

Include education about safety with each type ofactivity.

Teach the client safety measures to consider whenincreasing activity:

• Always check with a physician before starting an exer-cise program.

• Stop and consult a health-care professional if pain orunusual symptoms occur (e.g., chest pain, palpitations,irregular heart beat, dizziness, light-headedness, nau-sea, vomiting, extreme fatigue, pale or splotchy skin,“cold sweat”).

• Start in small increments and increase as tolerated.• Avoid exercising for 2 hours after a large meal and do

not eat for 1 hour after exercising.• Include warmup and cool down exercises.• Use proper equipment and clothing.• Wear comfortable rubber soled shoes and loose

clothing.• Avoid exercising in extreme heat or cold.90

Provides a baseline for planning activities and increasein activities.

Assists the client in utilizing existing resources.

Assists the client in making informed decisions.

Promotes safety.



••••••

SELF-CARE DEFICIT (FEEDING,BATHING-HYGIENE, DRESSING-GROOMING, TOILETING)

DEFINITION22

An impaired ability to perform or complete feeding,bathing-hygiene, dressing-grooming, or toileting activitiesfor oneself.


A. Feeding Self-Care Deficit1. Inability to swallow food2. Inability to prepare food for ingestion3. Inability to handle utensils4. Inability to chew food5. Inability to use assistive devices6. Inability to get food onto utensil7. Inability to open containers8. Inability to manipulate food in mouth9. Inability to ingest food safely

10. Inability to bring food from a receptacle to themouth

11. Inability to complete a meal12. Inability to ingest food in a socially acceptable

manner13. Inability to pick up cup or glass14. Inability to ingest sufficient food

B. Bathing-Hygiene Self-Care Deficit1. Inability to get bath supplies2. Inability to wash body or body parts3. Inability to obtain or get to water source4. Inability to regulate temperature or flow of bath

water5. Inability to get in and out of bathroom6. Inability to dry body

C. Dressing–Grooming Self-Care Deficit1. Inability to choose clothing2. Inability to use assistive devices3. Inability to use zippers4. Inability to remove clothes5. Inability to put on socks6. Inability to put clothing on upper body7. Impaired ability to put on or take off necessary items

of clothing8. Impaired ability to obtain or replace articles of

clothing9. Inability to maintain appearance at a satisfactory

level10. Inability to put clothing on lower body11. Inability to pick up clothing12. Inability to put on shoes

D. Toileting Self-Care Deficit1. Inability to manipulate clothing2. Unable to carry out proper toilet hygiene3. Unable to sit or rise from toilet or commode4. Unable to flush toilet or commode

RELATED FACTORS22

A. Feeding Self-Care Deficit1. Weakness or tiredness2. Severe anxiety3. Neuromuscular impairment4. Pain5. Perceptual or cognitive impairment6. Discomfort7. Environmental barriers8. Decreased or lack of motivation9. Musculoskeletal impairment

B. Bathing–Hygiene Self-Care Deficit1. Decreased or lack of motivation2. Weakness or tiredness3. Severe anxiety4. Inability to perceive body part or spatial relationship5. Perceptual or cognitive impairment6. Pain7. Neuromuscular impairment8. Musculoskeletal impairment9. Environmental barriers

C. Dressing-Grooming Self-Care Deficit1. Decreased or lack of motivation2. Pain3. Severe anxiety4. Perceptual or cognitive impairment5. Neuromuscular impairment6. Musculoskeletal impairment7. Discomfort8. Environmental barriers9. Weakness or tiredness

D. Toileting Self-Care Deficit1. Environmental barriers2. Weakness or tiredness3. Decreased or lack of motivation4. Severe anxiety5. Impaired mobility status6. Impaired transfer ability7. Musculoskeletal impairment8. Neuromuscular impairment9. Pain

10. Perceptual or cognitive impairment


1. Cerebrovascular accident2. Spinal cord injury3. Dementia4. Depression5. Rheumatoid arthritis


Activity IntoleranceThis diagnosis implies that the individual is freely ableto move but cannot endure or adapt to the increased


Self-Care Deficit (Feeding, Bathing-Hygiene, Dressing-Grooming, Toileting) 387

••••••

energy or oxygen demands made by the movement oractivity. Activity Intolerance can be a contributing fac-tor to the development of self-care deficits.

Impaired Physical MobilityThis diagnosis is quite often a contributing factor tothe development of Self-Care Deficit. It is probablethat any time a patient has Impaired Physical Mobility,he or she will also have some degree of Self-CareDeficit.

Disturbed Thought ProcessIf the patient is exhibiting impaired attention span;impaired ability to recall information; impaired percep-tion, judgment, and decision making; or impairedconceptual and reasoning ability, the most proper diag-nosis would be Disturbed Thought Process. Most likely,Self-Care Deficit would be a companion diagnosis.

Ineffective Individual Coping or Compromisedor Disabled Family CopingSuspect one of these diagnoses if there are major dif-ferences between reports by the patient and the fam-ily of health status, health perception, and health carebehavior. Verbalizations by the patient or the family

regarding inability to cope also require looking atthese diagnoses.

Interrupted Family ProcessesThrough observing family interactions and communi-cation, the nurse may assess that Interrupted FamilyProcesses should be considered. Poorly communi-cated messages, rigidity of family functions and roles,and failure to accomplish expected family develop-mental tasks are a few observations to alert the nurseto this possible diagnosis.

EXPECTED OUTCOME

Will return-demonstrate, with 100 percent accuracy, [spec-ify] self-care by [date].

TARGET DATES

Overcoming a self-care deficit will take a significant invest-ment of time; however, 7 days from the date of diagnosiswould be appropriate to check for progress.


Adult Health

● N O T E : Self-care deficits range from a total self-care deficit to very specific areas ofself-care deficits, such as bathing-hygiene or feeding. The nursing actions presented aregeneral in nature and would need to be adapted to fit the exact self-care deficit of theindividual. Collaboration with a rehabilitation nurse clinician and/or review of rehabili-tation literature would be excellent sources for current and specific nursing actionsrelated to a patient’s particular self-care deficit. Review of the nursing actions forUrinary Incontinence, Activity Intolerance, Impaired Physical Mobility, Impaired SkinIntegrity, and Imbalanced Nutrition will also be helpful.


Provide an environment that facilitates self-care:• Arrange food or furniture that addresses visual deficits.• Obtain assistive devices such as raised toilet seats or

shower seats, buttonhooks, angled extension comb andbrush.

• Place items within reach.

Provide extra time for giving daily care, and include:• Teaching• Return-demonstration of self-care activities• Emotional support

Provide privacy and safety for the patient to practice self-care.

Remind the patient to wear corrective appliances (e.g.,braces, prostheses, or eyeglasses).

Instills trust, avoids overwhelming the patient, facilitatesself-motivation, and allows immediate feedback onself-care.

Avoids embarrassment for the patient, provides basicsafety, and allows practice under closely supervisedsituation.

Promotes self-care by offsetting present limitations.




••••••


Adult Health


Provide positive reinforcement for each self-care accom-plishment.

Perform ROM exercises, or assist the patient with every 4hours while the patient is awake at [times].

Assist the patient and significant others in planning meas-ures to overcome or adapt to self-care deficits:

• Gradual increments in self-care responsibility (e.g.,getting up in chair independently before ambulating tobathroom by self)

• Self-care assistive devices (e.g., helping hand)Place a visual aid in the room to help document progress.Monitor:• Vital signs every 4 hours while the patient is awake at

[times].• Ambulation: Increase, to extent possible.

Monitor bowel and bladder elimination at least once dailyat [time].

Establish bowel- and bladder-retraining programs as nec-essary. (See Bowel Incontinence and UrinaryIncontinence, Chapter 4.)

Collaborate with dietitian regarding diet (e.g., foods tofacilitate self-feeding).

Refer the patient to community support services.

Make a home health referral to assist significant others toadapt home environment, as soon as feasible:

• Nonskid rugs• Ramps• Handrails• Safety strips in tub and shower

Increases self-esteem and motivation.

Maintains muscle tone and joint mobility.

Promotes timely home care planning and encourages par-ticipation in care.

Visually documents success.

Allows evaluation of progress and assist in determiningphysiologic impact of progress.

Baseline data that assist in determining bowel functioningpattern.

Provides basic education, practice, and reinforcement thatfacilitate the patient’s control of these functions.

Promotes self-care, and provides motivation to continuestriving for improvement.

Provides for long-term support.

Provides time to adapt home for basic safety measures.

Child Health

Adult Health care plan can provide the foundation for care of children with the following adaptations/considerations:


Monitor the patient’s and parents’ potential for self-caremeasures appropriate to age and developmental factors.

Allow the patient and parents to participate in planningfor care when possible to help ensure best compliance.[Note plan for including the family here.]

Teach the appropriate skills necessary for self-care in thechild’s terms, with sensitivity to developmental needsfor practice, repetition, or reluctance. [Note client-specific plan here.]

Provide opportunities that will enhance the child’s confi-dence in performing self-care. [Note plan for this clienthere.]

Provides a database for an individualized plan of care.

Enhances satisfaction, and increases the likelihood thatcare will be continued after discharge from hospital.

Individualized teaching best affords reinforcement oflearning. Sensitivity to special need attaches value tothe patient and family’s needs.

Confidence in self-care will enhance self-esteem.



••••••

Women’s Health

● N O T E : These activities relate to the new mother, their self care, and care of infantduring the first postpartum days. Other activities will apply to women the same asAdult Health, Gerontic Health, and Home Health.


Encourage the patient to list lifestyle adjustments thatneed to be made.

Encourage progressive activity and increased self-care astolerated:

• Ambulation• Bathing• Body image and early postpartum exercises• Bowel care• Breast care• Perineal care

Encourage the patient to get adequate rest:• Take care of self and baby only.• Let significant other take care of the housework and

other children.• Learn to sleep when the baby sleeps.• Have specific, set times for friends or relatives to visit.• If breastfeeding, significant other can bring the infant

to the mother at night (the mother doesn’t have to getup every time for the infant).

Provide quiet, supportive atmosphere for interaction withthe infant.

Instruct the patient in infant care, and have her return-demonstrate:

• Bathing• Never leave the infant or small child alone in bath.• Bathe the infant in a small area (the kitchen sink is

good) for the first few weeks.• Use a warm area in the house.• Use an area convenient for the mother.• Be sure the area is not drafty.• Never run water directly from the faucet onto the

infant; always test with a forearm before placing theinfant in water (water should be warm, but not toohot).

• Cord care• Clean the cord with alcohol and cotton swabs when

changing diapers.• Clean around the base of the cord.• Leave the cord alone until it drops off.• Alert the mother that there will be a small amount of

spotting (bleeding) at the cord site when it drops off.• Clothing

• To determine whether the infant is warm enough, feelthe infant’s chest or back with hand; never judge theinfant’s body temperature by feeling the infant’shands or feet.

Promotes gradual assumption of self-care while avoidingoverwhelming the patient with activities that must beaccomplished.

Promotes attachment.

Basic teaching measures for care of newborn.




••••••


Women’s Health


• Use a mild detergent when laundering the infant’sclothing

• Diapering• Cloth diapers• Disposable diapers• Cleaning of the infant when changing diapers

• Circumcision care—Yellen clamp (metal clamp)• Gently wash the penis with water to remove urine and

feces.• Reapply fresh, sterile Vaseline gauze around glans.• It is best to use cloth diapers until completely healed

(approximately 7 to 10 days).• Circumcision care—plastic bell

• Gently wash the penis with water to remove urine andfeces.

• Do not apply petrolatum gauze.• Leave the plastic circle on the penis alone until tissue

heals and circle falls off.• Taking the baby’s temperature and reading a ther-

mometer:• Axillary• Rectal

Explain infant alert and rest states and how the caretakercan best use these states to interact with the infant.

Promotes attachment.

Mental Health


Determine the client’s optimum level of functioning andnote here.

Develop behavioral short-term goals by:• Listing those activities the client can assume• Breaking these activities into their component parts• Determining how much of each activity the client could

successfully complete, and listing achievable activitieshere with goal achievement dates

• Discussing expectations with the client

Keep instructions simple.

Provide support to the client during tasks by:• Spending time with the client while he or she is com-

pleting the task.• Having all items necessary to achieve task readily

available.• Assisting the client in focusing on the task at hand.• Providing positive verbal feedback as each step of the

task is achieved.

This information assists in establishing realistic goals.

Goal accomplishment provides positive reinforcementand enhances self-esteem.

Inappropriate levels of sensory stimuli can contribute tothe client’s sense of disorganization and confusion.

Interaction with the nurse can be a source of positivereinforcement.

Increases the possibility for the client to complete thetask successfully.

Positive feedback encourages behavior.



••••••


Keep the environment uncluttered, presenting only thoseitems necessary to complete the task in the order needed.

Develop a reward schedule for achievement of goals.Discuss possible rewards with the client, and list thethings the client finds rewarding here with the goal tobe achieved to gain the reward.

Schedule adequate time for the client to accomplish task(depressed client may need 2 hours to bathe and dress).[Note the client’s schedule here.]

Decrease environmental stimuli to the degree necessaryto assist the client in focusing on task. [Note theclient’s adaptations here.]

Present ADLs on a regular schedule and note that sched-ule here. This schedule should be developed in consul-tation with the client.

Spend [number] minutes with the client twice a day dis-cussing feelings and reactions to current progress andexpectations. Times for this and person responsible forthis activity should be listed here.

Allow the client to perform activities even though itmight be easier at times for staff to complete the taskfor the client.

Communicate expectations and goals to all staff mem-bers.

Discuss with the family and other support systems andthe client the plan and goals. Spend at least 5 minuteswith the family after each visit to answer questions andexplain treatment plan.

Have members of support system identify how they canassist the client in achieving established goals.

Spend time with the client discussing alternative waysof coping with the frustration that may occur whileattempting to reach established goals.

Collaborate with the occupational therapist or physicaltherapist regarding special adaptations needed to assistthe client with task accomplishment (e.g., exercises toincrease muscle strength when muscles have not beenused for a period of time).

Monitor effects medications might have on goal achieve-ment, and collaborate with the physician regardingproblematic areas.

Develop goals and schedules with the client, communi-cating that he or she does have responsibility and con-trol in issues related to care.

Discuss with the client and significant others the thingsthat will facilitate continuance of self-care at home,and develop a plan that will assist the client in obtain-ing necessary items.

Refer to community resources as necessary for continuedsupport.

Inappropriate levels of sensory stimuli can contribute tothe client’s sense of disorganization and confusion.

Promotes the client’s sense of control. Positive feedbackencourages behavior.

Communicates acceptance of the client, which facilitatesthe development of trust and self-esteem.


Expression of feelings in a safe environment can facilitateproblem identification and the development of copingstrategies.

Communicates trust, and promotes the client’s sense ofcontrol.

Promotes consistency in the treatment, and communicatesrespect for the client.

Increases potential for success of treatment plan.

Promotes the client’s sense of control when encounteringthese difficulties. Successful coping will promote posi-tive self-esteem.

Facilitates the development of positive coping strategies,and increases potential for success when the clientreturns home. Successful accomplishment of this tran-sition promotes positive self-esteem.




••••••


Gerontic Health



Teach self-monitoring skills such as maintaining a journalor diary to record what factors may increase the self-care deficit.

Contract with the patient for achievement of specificincremental goals, and provide rewards or reinforce-ments when goals are met.

Encourages the patient to identify areas that may needimprovement or changes in lifestyle.91

Enhances motivation to increase self-care.

Home Health


Monitor factors contributing to self-care deficit of[specify]. This includes items in the related factorssection.

Involve the client and family in planning, implementing,and promoting reduction of the specific self-caredeficit:


Assist the client and family to obtain assistive equipmentas required:

• Raised toilet seat• Adaptive equipment for eating utensils, combs,

brushes, etc.• Rocker knife• Suction device under plate or bowl• Wrist or hand splints• Blender, crock pot, or microwave• Long-handled reacher (helping hand)• Box on seat of chair• Raised ledge on utility board• Straw and straw holder• Washcloth with soap• Wheelchair, walker, motorized cart, or cane• Bedside commode, incontinence undergarments• Bars and attachments and benches for shower or tub• Hand-held shower device• Long-handled sponge• Shaver holder• Medication organizers and magnifying glass• Diet supplements• Hearing aid• Corrective lenses

Provides a database for prevention and/or early inter-vention.


Assistive equipment improves function and increases thepossibilities for self-care.


Spontaneous Ventilation, Impaired 393

••••••


• Dressing aids: dressing stick, zipper pull, buttonhook,long-handled shoehorn, shoe fasteners, or Velcro clo-sures

Teach the client and family signs and symptoms ofoverexertion:

• Pain• Fatigue• Confusion• Decrease or excessive increase in vital signs• Injury


• Proper use of assistive equipment• Adapting to need for assistance or assistive equipment• Determining criteria for monitoring the client’s ability

to function unassisted• Time management• Stress management• Development of support systems• Learning new skills• Work, family, social, and personal goals and priorities• Coping with disability or dependency• Providing environment conducive to self-care privacy,

pain relief, social contact, and familiar and favorite sur-roundings and foods

• Prevention of injury (falls, aspiration, burns, etc.)• Monitoring of skin integrity• Development of consistent routine• Mechanism for alerting family members to need for

assistance

Refer the patient to appropriate assistive resources asindicated.

Planning activities around physical capabilities preventsfurther reduction in self-care capacity.



SPONTANEOUS VENTILATION,IMPAIRED

DEFINITION22

A state in which the response pattern of decreased energyreserves results in an individual’s inability to maintainbreathing adequate to support life.21


1. Dyspnea2. Increased metabolic rate3. Increased pCO24. Increased restlessness5. Increased heart rate6. Decreased tidal volume7. Decreased pO2

8. Decreased cooperation9. Apprehension

10. Decreased SaO211. Increased use of accessory muscles

RELATED FACTORS22

1. Respiratory muscle fatigue2. Metabolic factors


1. Chronic obstructive pulmonary disease (COPD)2. Asthma3. Closed head injury4. Respiratory arrest5. Cardiac surgery6. Adult respiratory distress syndrome (ARDS)



Ineffective Breathing PatternIn this diagnosis, the patient’s respiratory effort isinsufficient to maintain the cellular oxygen supply.Both diagnoses would contribute to the patient beingplaced on ventilatory assistance; however, ImpairedSpontaneous Ventilation is a more life-threatening,critical diagnosis than just an Ineffective BreathingPattern. The major difference would be the critical-ness of the patient’s condition.

Impaired Gas ExchangeThis diagnosis refers to the exchange of oxygen andcarbon dioxide in the lungs or at the cellular level.Both this diagnosis and Impaired Spontaneous

Ventilation demonstrate this characteristic, butImpaired Spontaneous Ventilation is of a more criticalnature than impairment.

EXPECTED OUTCOME

Blood gases will return to normal range by [date].

TARGET DATES

Because of the life-threatening potential of this diagnosis,initial target dates will need to be stated in terms of hours.After the patient’s condition has improved and stabilized,the target date can be increased in increments of 1 to 3 days.


••••••


Adult Health


Monitor ventilator, ventilator settings, and patientresponse to therapy at least hourly.

Provide sedation if needed.

Monitor lab work and other data including oxygen satura-tion, arterial blood gases, and lung sounds.

Implement actions that support adequate gas exchange.See nursing actions for Impaired Gas Exchange

Provide adequate hydration. Monitor and documentintake and output at least every shift, total every 24hours. Weigh the patient daily at same time and insame-weight clothing.

Plan the activity–rest schedule on a daily basis. Allow atleast 2 hours of uninterrupted rest during the day.

Review the patient’s resources and support systems formanagement of a ventilator at home.

Reassure the patient’s family while the patient is onventilator.

Collaborate with respiratory therapists as needed.

Ensures correct functioning of equipment.

Allows therapeutic effect of ventilation by preventingthe patient from working against (“bucking”) the venti-lator.

Monitors the effectiveness of therapy.

Avoids fluid-volume deficit, assists in liquefying secre-tions, and prevents development of pulmonary edema.

Conserves energy and promotes REM (rapid eye move-ment) sleep.

Initiates timely home care planning.

Ensures coordination of care.

Child Health


Determine parameters for respiratory status:• Range of acceptable rate, rhythm, and quality of respi-

ration• Limits for apnea monitor setting.92 The settings should

be set for a range of safety according to age-relatednorms:

A specific respiratory assessment will help individualizethe need plan of care.


Spontaneous Ventilation, Impaired 395

••••••


• Neonates: 30–60• Infants: 25–60• Toddlers: 24–40• Preschoolers: 22–34• Adolescents: 12–16

• Arterial blood gases• Oxygen saturation levels• Respiratory testing (e.g., pneumogram)• Other indicators of respiratory function (e.g., cyanosis,

mottling, diminished pulses, listless behavior, poorfeeding, or vital signs)

Provide one-to-one care for infants and children at riskfor apnea or pulmonary arrest.

Keep emergency medications and equipment (Ambu bag,airway, suctioning equipment, crash cart, ventilator,and oxygen) in close proximity.

Administer medication as ordered, being careful inadministration of medications that might affect respira-tions (e.g., narcotics, bronchodilators, or vasoconstric-tors). Monitor blood levels for therapeutic parametersof aminophylline–theophylline. Report levels above orbelow the desired range.

Spend [number] minutes per shift with the family. Duringthis time, focus on their concerns about the patient’srespiratory status.

Allow parental input as an option when it is realistic.

Carry out teaching according to inquiries by the patientor family. [Note special teaching needs here.]

Check level of consciousness (responsiveness) at leastevery 30 minutes.

Monitor and document episodes of crying that result inapnea or loss of usual color for prolonged periods (15seconds or more).

Exercise caution in feeding or offering fluids.

Monitor for contributing factors to problem:• Central nervous system status• Airway• Chest wall• Respiratory muscles• Lung tissue

ADDITIONAL INFORMATION: Be aware of the majornursing considerations involved in the legal regulationsrelated to brain death determination in children in theevent of a decision to withhold or cease use of the venti-lator for the purpose of determining brain death.

In high-risk respiratory patients, the possibility of arrestshould be planned for. Identification of the actual arrestis a major factor in successful resuscitation.

Success in appropriate treatment of pulmonary arrestrequires anticipatory planning with standard treatmentmodalities according to the American HeartAssociation guidelines and Pediatric Advanced LifeSupport guidelines.

Anticipatory planning for the possibility of respiratorydepression or arrest will lessen the likelihood of actual-ity in many instances and serve to allow for more suc-cess in treatment of these problems. If neuromuscularblocking agents are utilized, exercise caution in posi-tioning because of the possibility of dislocation.70,93

Verbalization of concerns helps reduce anxiety and pro-vides subjective data for assessment and an opportunityfor teaching.

Parental involvement provides emotional security for thechild and reinforces parental coping.

Individualized learning is facilitated when it is directedtoward stated needs.

Decreased responsiveness is indicative of onset of respi-ratory failure.

Breath-holding or crying may seem to cause hypoxia, butoften there are underlying causes. Attention to underly-ing cause can be carried out, but vigilance for possiblearrest is necessary.

Possible aspiration is likely if the infant is apneic, unableto suck well, or has problems swallowing.

Alteration in any aspect of respiratory anatomy will affectadequate ventilation.



TISSUE PERFUSION, INEFFECTIVE(SPECIFY TYPE: RENAL, CEREBRAL,CARDIOPULMONARY,GASTROINTESTINAL, PERIPHERAL)

DEFINITION22

A decrease in oxygen resulting in failure to nourish the tis-sues at the capillary level.21


1. Renala. Altered blood pressure outside of acceptable parame-

tersb. Hematuriac. Oliguria or anuriad. Elevation in blood urea nitrogen (BUN) and/or creati-

nine ratio2. Cerebral

a. Speech abnormalitiesb. Changes in pupillary reactionsc. Extremity weakness or paralysisd. Altered mental statuse. Difficulty in swallowing

f. Changes in motor responseg. Behavioral changes

3. Cardiopulmonarya. Altered respiratory rate outside of acceptable parame-

tersb. Use of accessory musclesc. Capillary refill greater than 3 secondsd. Abnormal arterial blood gasese. Chest painf. Sense of “impending doom”g. Bronchospasmsh. Dyspneai. Arrhythmiasj. Nasal flaringk. Chest retraction

4. Gastrointestinala. Hypoactive or absent bowel soundsb. Nauseac. Abdominal distentiond. Abdominal pain or tenderness

5. Peripherala. Edemab. Altered skin characteristics (hair, nails, and moisture)c. Weak or absent pulses


••••••


Women’s Health

The nursing actions for Women’s Health are the same as those for Adult Health.

Mental Health

● N O T E : If the client develops this diagnosis while being cared for in a mental healthunit, he or she should immediately be transferred to an intensive care unit or adulthealth unit. A mental health unit is not equipped to handle this type of emergency.

Gerontic Health


Monitor for iatrogenic reactions to medications.

Observe for signs and symptoms of sleep-pattern dis-turbance.

Medication reactions may decrease respiratory drive andeffort.

Decreased rest secondary to sleep-pattern disturbancesfurther diminishes physiologic reserves in olderpatients.94

Home Health

N O T E : Should the home health client develop this diagnosis, the nurse should immedi-ately have the client transferred to an acute care setting for the proper care.


Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) 397

••••••

d. Skin discoloratione. Skin temperature changesf. Altered sensationsg. Claudicationh. Blood pressure changes in extremitiesi. Bruitsj. Delayed healingk. Diminished arterial pulsationsl. Skin color pale on elevation, color does not return on

lowering leg

RELATED FACTORS22

1. Hypovolemia2. Interruption of arterial flow3. Hypervolemia4. Interruption of venous flow5. Mechanical reduction of venous and/or arterial blood

flow6. Hypoventilation7. Impaired transport of oxygen across alveolar and/or

capillary membrane8. Mismatch of ventilation with blood flow9. Decreased hemoglobin concentration in blood

10. Enzyme poisoning11. Altered affinity of hemoglobin for oxygen


1. Thrombophlebitis2. Amputation reattachment3. Varicosities4. Diabetes mellitus5. Cardiac infections6. Anemia7. Myocardial infarction8. Coronary artery disease9. Kawasaki’s disease

10. Congestive heart failure11. Congenital cardiac anomalies12. Coronary artery aneurysm


Decreased Cardiac OutputIneffective Tissue Perfusion relates to deficits in theperipheral circulation with cellular impact. DecreasedCardiac Output relates specifically to a heart malfunc-tion. Tissue perfusion problems may develop second-ary to decreased cardiac output but can also existwithout cardiac output problems.105

EXPECTED OUTCOME

Signs or symptoms of Ineffective Tissue Perfusion (notedefining characteristics for this client here, e.g., pulse pres-sure, pulses, skin color, blood pressure) will be within nor-mal limits by [date].

TARGET DATES

A maximum target date would be 2 days from the date ofadmission because of the dangers involved. A patient whodevelops this diagnosis should be referred to a medical prac-titioner immediately.


Perfusion is the movement of blood to and from a body part.Adequate perfusion determines cell survival and depends onan adequate pump and vascular volume, as well as adequatefunctioning of the precapillary sphincters. The adequacy ofthese structures is affected by, among others, vasomotor,metabolic, and neural factors.58,95

The basic function of the cardiovascular system is totransport water, oxygen, nutrients, and hormones to the cellsand to remove carbon dioxide, waste products, and heat fromthe cells. The size of the blood vessels decreases along thelength of the arterial system, which increases resistance tofluid flow. To perfuse the cells adequately, the mean arterialblood pressure is maintained within a relatively narrow rangeby such regulatory systems as the baroreceptors, sympatheticnerves, and the cardiac branch of the vagus nerve.58,95


Adult Health


Adequate tissue perfusion is contingent on, among otherfactors, maintaining adequate fluid volume and ade-quate cardiac output. See nursing actions in these areasto ensure these areas are being met.

If situation allows, facilitate early ambulation

Ensure DVT prophylaxis has been implemented.(care plan continued on page 398)



••••••


Adult Health


Address and remove any physical or chemical factors thatinterfere with circulation.

Implement measures to optimize adequate cerebral per-fusion:

• Avoid undue elevations of ICP, maintain cerebral perfu-sion pressure

• Implement actions to avoid vasospasm includingadministration of appropriate medications and HHHtherapy as prescribed by the health-care team

• Maintain blood pressure within prescribed therapeuticrange as determined by health-care team

Collaborate with the health-care team regarding medica-tions that can improve perfusion such as vasopressorsand positive inotropes.

Implement strategies that decrease myocardial oxygenconsumption (e.g., negative chronotropes).

Maintain euthermia.

Assure that areas susceptible to pressure are addressed(e.g., casts, endotracheal tube pilot balloon).

Assess circulation to sites distal to temporary equipment(e.g., venous access devices, IABP).

Interpret data including lab work, hemodynamic moni-toring, ICP

Maintains cerebral perfusion.

To monitor for adverse effects of large venous devices.

Determines efficacy of therapy and need for alternationof plan of care.

Child Health


Perform appropriate monitoring and documentation forcontributory factors to include:

• Circulatory monitoring of anatomic site or generalsigns and symptoms related to peripheral pulses

• Apical pulse, blood pressure, temperature, and respira-tion (monitor at least every hour or as ordered, andcheck cardiac monitor if applicable)

• Intake and output every hour• Nausea or vomiting• Constipation or diarrhea• Tolerance of feeding• Pain or discomfort• Skin color and temperature; any integrity problems• Circulatory pattern: Notify the physician for any

change in the pattern that suggests lack of oxygenation(e.g., cyanosis, arterial blood gas results, or decreasedpulses).

• Appropriate functioning of equipment, such as ventila-tor, arterial line, or intravenous pump

• Maintenance of intravenous line for administration offluids

Provides basic database to ascertain progress and to indi-vidualize plan of care.



••••••


• Positional demands• Pain or discomfort• Sensory input appropriate for age and developmental

status• Fluid and electrolytes

Collaborate with other health-care providers as needed.[Note special needs of collaboration here.]

Provide for appropriate availability of resuscitative equip-ment, including:

• Ambu bag• Crash cart for pediatrics with drugs and defibrillator• Appropriate respiratory intubation equipment

Allow for parental and child health teaching needs byallowing 10 to 15 minutes per 8-hour shift for verbal-ization of concerns. [Note special teaching needs here.]

Allow for parental participation in care of the child atappropriate level (e.g., giving comfort measures orassisting with feeding).

Provide rest by scheduling procedures together withample time between activities. Note the routine for thisclient here.

Allow patient and parental preferences in plan of care.Note those preferences here.

Deal with appropriate related factors associated with inef-fective tissue perfusion (e.g., minimizing crying byanticipating needs).

Provide appropriate safety for age (e.g., keeping siderailsup or positioning as ordered).

Maintain proper use of equipment, such as Clinitron bed,or special K-pads.

Provide for appropriate follow-up via scheduled appoint-ments after hospitalization. [Note follow-up plan here.]

Provide the patient with teaching appropriate to needs ofillness and family (e.g., if activities and daily care areto be modified, consider use of pulse oximeter to moni-tor perfusion, and explain how to do circulatory checksafter cast application). [Note teaching plan here.]

Ensure that the parents have been certified in CPR beforethe child is dismissed from hospital.

Coordination and implementation of plan of care mayinvolve numerous professionals according to the causeof alteration and the treatment modalities available.


Verbalization of health-related concerns may serve ascues for teaching needs and also serves to reduceanxiety.

Parental involvement in care puts the child at ease andprovides self-esteem and empowerment for the parents.

Appropriate attention to rest needs helps prevent furthermetabolic demands on already less than ideal home-ostasis scenario. Consistency increases the sense ofsecurity.

Individualization shows value attached to parents’ input.

All efforts to lessen workload on heart and respiratorysystem will assist in preventing further decompensa-tion.

Safety is a standard part of care and ought to be plannedfor according to health status, age, and development.

Assists circulation.

Encourages consistency in long-range care. Demonstrateshow to schedule appointments, and provides supportfor parents.

Assists in reducing anxiety, and facilitates home manage-ment of care.

Basic need for home care when perfusion problem ispresent.

● N O T E : A major effort will be that of follow-up with appropriate special-ized care to include pediatric cardiology and, as needed, other expertise toanticipate a long course of therapy. Care is focused on early diagnosis,especially in instances of congenital cardiac anomaly (e.g., simple coro-nary artery malformation versus that associated with other related physio-logic malformation of the heart and vasculature). A specific concern isKawasaki’s disease, with a residual concern of coronary artery aneurysm.Periodic echocardiography is mandated for those individuals.




••••••


Women’s Health

● N O T E : In instances of decreased coronary tissue perfusion, the women’s healthclient should immediately be transferred to a coronary care unit.


Assist the patient in identifying lifestyle adjustments thatmay be needed because of changes in physiologicfunction or needs during experiential phases of life(e.g., pregnancy, birth, postpartum and related to gyne-cology):

• Avoid prolonged sitting, sitting with crossed legs, orstanding.

• Develop exercise plan for cardiovascular fitness duringpregnancy.

• Avoid wearing constrictive clothing.• Maintain a balanced diet with adequate hydration.• Avoid constipation and bearing down to prevent hemor-

rhoids.

Monitor the patient for signs of pregnancy-inducedhypertension (PIH):

• Prenatal weight• Blood pressure• Presence of edema• Proteinuria• Pre-eclampsia• Headaches• Visual changes such as blurred vision• Increased edema of face and pitting edema of extremi-

ties• Oliguria• Hyperreflexia• Nausea or vomiting• Epigastric pain• Eclampsia• Convulsions• Coma

Monitor for edema:• Swelling of hands, face, legs, or feet.• Caution: The patient may have to remove rings.• The patient may need to wear loose shoes or a bigger

shoe size.• Schedule rest breaks during day when the patient can

elevate legs.• When the patient is lying down, he or she should lie on

the left side to promote placental perfusion and preventcompression of vena cava.

In collaboration with physician (as appropriate):• Check intake and output (urinary output not less than

30 mL/h or 120 mL/4 h).

Decreases factors that could lead to decreased perfusionof oxygen to uterus, placenta, and fetus.

Allows early intervention to avoid perfusion problemsand development of complications.

Provides early warning of perfusion problems, and pro-motes early intervention.



••••••


• Use magnesium sulfate (MgSO4) and hydralazinehydrochloride (Apresoline) therapy according to physi-cian order. Have antidote for MgSO4 (calcium glu-conate) available at all times during MgSO4 therapy.

• Assess deep tendon reflexes (DTR).• Check respiratory rate, pulse, and blood pressure at

least every 2 hours on [odd/even] hour.• Evaluate for possibility of seizures.• Limit the amount of noise in the patient’s environment.• Monitor fetal heart rate and well-being.

Provide quiet, nonstimulating environment for the patient.

Provide the patient and family factual information andsupport as needed.

Monitor and teach the patient to monitor and report anysigns of PIH immediately:

• Rapid rise in blood pressure• Rapid weight gain• Marked hyperreflexia, especially transient or sustained

ankle clonus• Severe headache• Visual disturbances• Epigastric pain• Increase in proteinuria• Oliguria, with urine output of less than 30 mL/h• Drowsiness

In collaboration with dietitian:• Obtain nutritional history.• Provide a high-protein diet (80–100 grams of protein).• Provide low-sodium diet (not more than 6 grams daily

or less than 2.5 grams daily).

Oral Contraceptive TherapyMonitor for factors that contraindicate use of oral birth

control.• Family history of stroke, diabetes, or reproductive

cancer• History of thromboembolic disease or vascular prob-

lems, hypertension, hepatic disease, and smoking• Presence of any breast disease, nodule, or fibrocystic

disease

Reduces anxiety and promotes rest. Both measures willassist in maintaining peripheral circulation by avoidingvasoconstriction.

Reduces anxiety and provides teaching opportunity.

Allows early detection of problem and more rapid inter-vention.

Dietary measures that assist in controlling blood pressure.

These factors promote side effects and untoward effectsfrom birth control pills.

Mental Health

● N O T E : The nursing actions in this section reflect alteration in tissue perfusionrelated to the cerebral and peripheral vascular systems, because these are the systemsmost commonly affected in the mental health setting.




••••••


Mental Health


Check on orthostatic hypotension by taking blood pres-sure while the client is lying down, then taking bloodpressure just after the client stands or sits up (providesupport for the client to prevent injury from a fall).

Monitor the client’s mental status. If compromised, pro-vide information in a clear, concise manner.

Discuss with the client causes of decreased cerebralblood flow.

Have the client get out of bed slowly by:• Sitting up• Swinging legs over edge of bed• Resting in this position for at least 2 minutes• Standing up slowly• Walking slowly

Teach the client to avoid situations in which he or shechanges position quickly (e.g., bending over to picksomething up off the floor or standing quickly from asitting position).

Have the client supported while changing positions thatcause vertigo until problem is resolved.

Assist the client in getting in and out of the bathtub.

Collaborate with physician regarding alterations in med-ications.

If situation persists, have the client:• Sleep sitting up or with head elevated.• Use elastic stockings that are waist high.• Apply stockings while the client is still in bed.• Have the client raise legs for several minutes.• Apply stockings slowly and evenly.• Remove stockings after the client is lying down at least

every 8 hours.

Develop with the client a plan for daily exercise that isvery modest (e.g., walking the length of the hall for15 minutes twice a day for 3 days, then increasing dis-tance and time gradually until the client is walking for30 minutes twice a day). [Note the client’s exerciseregimen here.]

Develop with the client a reward schedule for implement-ing exercise plan. [List rewards and the reward sched-ule here.]

Provide the client with positive verbal support for goalaccomplishment.

Do not allow the client to participate in unit activities thatcould produce injury until the condition is resolved(e.g., cooking or using sharp objects while standing).

Psychotropic medications can predispose the client toorthostatic hypotension.

Assists in explaining reasons for therapies to the client.

Allows time for cardiovascular system to adapt, thus pre-venting fainting or dizziness due to orthostatichypotension.

Promotes changing to a medication that would not inter-fere with perfusion.

Provides external support for venous system.

Improves cardiovascular strength. Assists in maintainingmuscle tone, which assists in supporting the venouscirculation.




••••••


Discuss with the client the effects of alcohol and smokingon blood flow, and assist him or her to develop alterna-tive coping behavior if necessary. [Note plan for thishere.]

Provide decaffeinated beverages for the client. Consultwith the dietary department about this adaptation.

Increase the client’s fluid intake during times of increasedloss, such as exercise or periods of anxiety. Instruct theclient in the need for this.

Observe the client carefully after injecting medicationsthat have a high potential for producing hypotension.This is especially true for clients who are very agitatedand physically active.

Inform the client of need to change position slowly afterinjecting medication.

Teach the client and support system about over-the-counter medications that alter blood flow (e.g., coldmedications, antihistamines, or diet pills).

Monitor peripheral pulses on affected limbs every 8 hoursat [times].

Avoid, and teach the client to avoid, pressure in points onaffected limbs to include:

• Changing position frequently when sitting or lyingdown

• Avoiding pressure in the area behind the knee• Not crossing legs while sitting• Making sure shoes fit properly and do not rub feet• Elevating feet when sitting to reduce pressure on backs

of legs

Keep feet clean and dry, and teach the client to do thesame by assessing foot condition once a day at [time].This assessment should include:

• Washing feet• Checking for sores, reddened areas, and blisters• Keeping toenails trimmed and caring for ingrown nails• Applying lotion to feet• Rubbing reddened areas if the client does not have a

history of emboli• Applying clean, dry socks• Teaching significant others to assist with foot care of

the elderly client• Keeping limbs warm (but do not use external heating

sources such as heating pads or hot-water bottles)

Develop with the client an exercise program, and notethat program here. Begin slowly, and graduallyincrease time and distance (e.g., walk for 15 minutes 2times per day for 1 week). This should be increaseduntil the client is walking 1 mile in 30 to 45 minutesthree times a week.

Basic measure to offset the possibility of falling second-ary to orthostatic hypotension.

Avoids compromising circulation by pressure or constric-tion.

Avoids lower extremity skin integrity problems and possi-ble infection with the resultant impact on circulation.

Promotes normal venous return.




••••••


Mental Health


Instruct the client to discontinue exercise if:• Pulse does not return to resting rate within 3 minutes

after exercise.• Shortness of breath continues for more than 10 minutes

after stopping exercise.• Fatigue is excessive.• Muscles are painful.• The client experiences dizziness, pain in the chest,

lightheadedness, loss of muscle control, or nausea.

Encourage the client’s exercise by:• Walking with him or her• Determining things that the client would find rewarding

and supplying these as goals are achieved• Providing positive verbal support as goals are

achieved [Note the client’s specific reward systemhere.]

Monitor the client’s nutritional status, and refer to nutri-tionist for teaching if necessary.

Discuss with the client the effects of smoking on periph-eral blood flow, and assist him or her in decreasing oreliminating this by:

• Referring the client to a stop-smoking group• Encouraging him or her not to smoke before meals or

exercise• Decreasing amount smoked per day

Discuss special needs with the client and support systembefore discharge.

Refer the client to community agencies to provide ongo-ing care as needed.

Client safety is of primary importance.

Nicotine causes vasospasm and vasoconstriction.

Increases probability of the client’s behavior changebeing maintained after discharge.

Gerontic Health

In addition to the interventions for adults, the following may be utilized for aging clients.


Monitor for signs of dyspnea, chronic fatigue, behav-ioral changes, or evidence of acute cerebral insuffi-ciency.

Plan physical activities, such as hygiene, meals, andambulation, with rest periods.

Instruct in use of oxygen, if prescribed.

Teach the client relaxation methods to help decreaseanxiety.

Older clients with decreased cardiac perfusion often pres-ent with these symptoms.

Decreases cardiac workload.

Supplemental oxygen may be prescribed to help decreasecardiac workload.

Decreasing anxiety helps decrease the release of cate-cholamines. An increase in catecholamines results inincreased cardiac workload.



••••••

Home Health

● N O T E : If this diagnosis is suspected when caring for a client in the home, it is imper-ative that a physician referral be obtained immediately. If a physician has referred theclient to home health care, the nurse will collaborate with the physician in the treatmentof the client.


Teach the client and family appropriate monitoring ofsigns and symptoms of alteration in tissue perfusion:

• Pulse (lying, sitting, and standing)• Skin temperature and turgor• Edema• Motor status• Sensory status• Blood pressure (lying, sitting, standing, and pulse pres-

sure)• Respiratory status (dyspnea, cyanosis, and rate)• Weight fluctuations• Urinary output• Leg pain with walking


• Eliminating smoking• Decreasing caffeine• Decreasing alcohol• Avoiding over-the-counter medications• Protecting skin and extremities from injury due to

decreased sensation (burns, frostbite, etc.)• Protecting skin from pressure injury (making frequent

position changes and using sheepskin for pressure areasand foot cradle)

• Improving arterial blood flow (keeping extremitieswarm, elevating head and chest, avoiding crossing legsor sitting for long periods of time, wiggling fingers andtoes every hour, and performing ROM exercises)

• Performing exercise program as tolerated• Improving venous blood flow (elevating extremity,

using antiembolus stockings, and avoiding pressurebehind knees)

• Performing skin and foot care• Decreasing cholesterol and saturated fat intake• Performing diversional activities as needed• Practicing stress management


Teach the client and family purposes, side effects, andproper administration technique of medications.

Assist the client and family to set criteria to help themdetermine when a physician or other intervention isrequired.

Assess the client/family need for assistive resources andrefer to community agencies that provide suchresources.

Provides database for prevention and/or early inter-vention.



Promotes safe adherence to the therapeutic regimen.




TRANSFER ABILITY, IMPAIRED

DEFINITION22

Limitation of independent movement between two nearbysurfaces.21


1. Impaired ability to transfer from bed to chair and chairto bed

2. Impaired ability to transfer on or off a toilet or com-mode

3. Impaired ability to transfer in and out of tub or shower4. Impaired ability to transfer between uneven levels5. Impaired ability to transfer from chair to car or car to

chair6. Impaired ability to transfer from chair to floor or floor to

chair7. Impaired ability to transfer from standing to floor or

floor to standing

RELATED FACTORS22

To be developed.


1. Arthritis2. Paralysis3. Neuromuscular diseases

4. Amputation5. Fractures


Impaired Physical MobilityCertainly anyone who had Impaired Transfer Abilitywould also have Impaired Physical Mobility. Theinability to transfer from one site to another wouldneed to be resolved before Impaired Physical Mobilitycould be resolved.

Ineffective Management of TherapeuticRegimen, IndividualA patient who cannot transfer himself or herselffrom one site to another could well have difficultywith managing a therapeutic regimen. However, thepatient will never be able to manage the therapeuticregimen until the problem with transfer ability isresolved.

EXPECTED OUTCOME

Will independently transfer self by [date].

TARGET DATES

Resolving this diagnosis requires an extended length oftime. An appropriate initial evaluation date would be 7 to 10days after the date the diagnosis is made.


••••••


Adult Health


Devise and implement a strength training regimen in con-junction with physical therapist.

• Devise a daily schedule.• Provide adequate periods of rest• Provide patient with implements to increase strength

(e.g., resistance bands, weights)

Provide the patient with assistive devices that enhanceability to transfer (e.g., trapeze, crutches, raised toiletseats, hand rails).

Provide the patient with appropriate accessories includingnon-skid slippers, appropriate fitting shoes, gloves.

Ensure that area to which the patient is transferring isappropriately prepared.

Utilize appropriate number of personnel to assist patient.

Ensure that patient has adequate nutritional intake to sup-port muscle development.

Refer the patient to nutrition services or devise weightloss plan if weight is the limiting factor.

Adequate strength is integral to movement betweensurfaces.

Facilitates transfer.

Ensures safety during transfer.

Reduces obstacles and ensures safety during transfer.


Transfer Ability, Impaired 407

••••••


Educate the patient about working with limitations andgradually increasing activity as physical ability allows.

Refer to rehabilitation facility as appropriate and as soonas feasible.

Gives patient realistic purview of progress through planof care.

Child Health


Determine all contributing factors, to include:• Neuromuscular• Cardiovascular• Pulmonary• Cognitive• Developmental• Situational

Determine augmentative devices, personnel, or environ-mental needs and have these available before transfer.[Note the client’s special needs here.]

Determine the client’s level of proprioception.

Determine strength and ability to coordinate body move-ments well in advance of attempted maneuver.

Schedule transfer activities in a timely manner when pos-sible. [Note the time needed for the client to performactivity here.]

Determine readiness for taking on task of transfer.

Determine need for teaching the client, family, or othercaregivers how to assist in transfer activities. [Noteteaching plan here.]

Determine a reward system to fit developmental status ofthe client for appropriate attainment of goal. [Notethose rewards and situations to be rewarded here.]

Schedule group teaching of transfer activities. [Noteschedule here.]

Determine need for adaptations related to the patient’schanging status and environmental needs. (Home andschool vs. hospital)

Allow sufficient time for teaching and mastery of transferif discharge may occur within short period of time.[Note teaching plan and schedule here.]

All possible factors are considered in providing a holisticdatabase for individualization.

Appropriate support ensures safety.

Prerequisite for each maneuver to increase likelihood ofsuccess.

Pre-assessment helps ensure safety needs are met.

Time to adjust and slowly incorporate concept of transferwill be best afforded in a leisure vs. crisis time frame.

Validation of readiness offers empowerment and a senseof control in attempt.

Teaching with focus on learner’s needs will most likelyease anxiety and afford consistency in safe manner.

Provides reinforcement of desired behavior.

Group behavior offers peer support.

Principles of safety may be altered yet upheld forchanges that occur.

Early teaching with plan for dismissal results in greaterlikelihood of attainment and may be reason to keeppatient until satisfied.

Women’s Health

The nursing actions for Women’s Health are the same as those for Adult Health.(care plan continued on page 408)


WALKING, IMPAIRED

DEFINITION22

Limitation of independent movement within the environ-ment on foot.21


1. Impaired ability to climb stairs2. Impaired ability to walk required distances3. Impaired ability to walk on an incline or decline4. Impaired ability to walk on uneven surfaces5. Impaired ability to navigate curbs

RELATED FACTORS22

To be developed.


1. Arthritis2. Chronic obstructive pulmonary disease3. Cerebrovascular accident4. Neuromuscular disorders5. Amputation involving lower extremities


Impaired Physical MobilityImpaired walking could be considered to be a subsetof Impaired Physical Mobility and is a more specificdiagnosis. If the patient is having difficulty only withwalking and not other aspects of mobility, such asmoving in bed and getting up and down in sitting,then Impaired Walking is the most correct diagnosis.

Activity IntoleranceThis diagnosis relates more to feeling fatigued orweakness while performing activities. Again, ActivityIntolerance is a broader diagnosis than ImpairedWalking.

EXPECTED OUTCOME

Will independently walk by [date].

TARGET DATES

Activities to facilitate walking with ease require weeks. Anappropriate evaluation target date would be 1 to 2 weeksfrom the day of admission.


••••••


Mental Health

The nursing actions for the mental health client are the same as those for Adult Health.

Gerontic Health

The nursing actions for Gerontic Health are the same as those for Adult Health.


The nursing actions for Home/Community Health are the same as those for Adult Health with the following additions:


Educate the client, family, and potential caregivers aboutthe following:

• Using proper body mechanics• Maintaining a clear wheelchair path

Assist the client in obtaining and proper use of a slidingboard.

Assist the client in developing a schedule for range ofmotion exercises.

Refer clients for a home physical therapy consult to helpthem maximize their ability to safely use a wheelchairat home and to have assistive devices appropriate forthe home environment.

Assists in avoiding injury.

Facilitates a safe transfer.

To maintain and build muscle strength.


Walking, Impaired 409

••••••


Adult Health


Determine the appropriate equipment and pattern basedon your assessment, and the goals of treatment.

Remove items in the area that may interfere with ambula-tion.

Explain and demonstrate the gait pattern for the patient;ask the patient to describe the pattern, how it is to beperformed, and what he or she is expected to do.

Be sure the patient is wearing appropriate footwear; donot allow the patient to ambulate while wearing slip-pers, loosely fitting shoes, or while not wearing shoes.

Monitor the patient’s physiologic responses to ambulationfrequently, and evaluate his or her vital signs, generalappearance, and mental alertness during the activity.Compare your findings to normal values to determinethe patient’s reaction to the activity.

See nursing actions related to impaired physical mobilityfor a plan of care that supports improvement of walk-ing.

Collaborate with Physical Therapy as needed.

To maintain a safe environment.

To verify that he or she truly understands and compre-hends your instructions.

These conditions can lead to patient insecurity and injuryas a result of a fall.

To assist in planning the ambulation activities.

Child Health


Monitor for all contributing factors including:• Orthopedic• Neurologic• Developmental• Situational

Monitor readiness for weight-bearing. Note exact limitsof activity with reliance on limbs, both lower andupper.

Assess for need for assistive devices or personnel forwalking activity.

Determine teaching needs for the client, family, or relatedassistants. [Note teaching plan here.]

Provide posture-appropriate alignment during walkingactivities.

Provide appropriate cautionary information when assis-tance is required for the patient’s walking. State when,what must be done, and with whom to meet prerequi-site walking behaviors.

Coordinate health-care team members and scheduling ofwalking activities. [Note collaboration plan here aswell as assistance needed from nursing staff to imple-ment plan.]

A complete assessment provides primary database forindividualization.

Validation of status of limbs and their capacity forweight-bearing is critical for safety and non-injurybefore ambulation is considered.

Appropriate augmentive aids help ensure safe activity.

Specific data for safety and likelihood of success is para-mount for all involved to feel empowered.

Lessens likelihood of related injury to spine or limbs.

Ensures likelihood of safe walking with appropriate atten-tion to limit setting to reinforce importance of plan.

The nurse is in the best position to provide safe and con-sistent care with total patient needs in mind.




••••••


Child Health


Provide safe environment, free of clutter or equipment, todegree possible.

Schedule medications to enhance success in walkingactivities. [Note schedule here.]

Seek assistance from Occupational and/or PhysicalTherapy to facilitate progress in walking activities.

Determine an appropriate reward system according to thepatient’s developmental capacity. [Note plan here.]

Provide opportunities for group teaching of walkingactivity as appropriate for the child’s developmentallevel.

If equipment is required, offer artistic opportunities forthe client to decorate same per developmental interest.

Determine need for discharge planning well before actualevent. [Note plan and person responsible for coordinat-ing this activity here.]

Discuss with the child and family a plan for adaptingmobility needs to school or other regular activities.

Lessens the likelihood for barriers or obstacles to freepath.

According to nature of medication, onset of action, half-life, side effects, or untoward effects, the best likeli-hood for walking without undesired effects is upheld.

Periodic regular assessment with appropriate health teammembers provides appropriate validation for safewalking.

Reinforces desired behavior.

Peer pressure and interaction offers diversionary stimulusto perform desired activity.

Self-expression provides a sense of identity for the client.

Prior planning permits sufficient time to safely masterwalking protocol in a supportive environment.

Anticipation of usual events of daily living to be reincor-porated in advance will lessen likelihood of unsafe orunsuccessful attempts to adapt lifestyle.

Women’s Health


Mental Health


Gerontic Health

In addition to the interventions for Adult Health, the following may be utilized with the aging client:


Collaborate with the physical therapist for assessmentand treatment plan to improve walking ability.

Ensure that any adaptive or assistive equipment (such asbraces, footwear, or eyeglasses) fit correctly and areproperly functioning.

Promote interdisciplinary team member communicationto ensure that plan of care is consistently applied.

Physical therapists are health-care professionals specializ-ing in problems related to the lower extremities andambulation skills.

Reduces potential for injuries when the client is walking.

Ensures continuity of care across disciplines and care set-tings.


Wandering 411

••••••


Monitor and report symptoms as needed from medica-tions (e.g., antihypertensives, diuretics, or psychotrop-ics) with side effects such as lightheadedness, ororthostatic blood pressure changes that may affect theclient’s ambulatory ability.

Encourage client participation in a walking program, ifavailable in care setting.

Teach the client and/or caregivers to check for environ-mental aids (e.g., handrails) or barriers (poorly fittingshoes, shiny floor surfaces, or cluttered pathways) towalking.

Promote use of activity programs, if available, that sup-port the goal of increasing walking ability in clients(e.g., Senior Olympic activities, exercises to promotelower extremity strengthening, or enhanced trunk con-trol and balance abilities).97

Older adults may require medication adjustments todecrease side effects that have a deleterious effect onambulation ability and safety.96,97

Promotes the client’s physical and psychological well-being.

Emphasizes safety focus prior to onset of activity.

Provides increased opportunities for older adults to prac-tice skills to enhance walking ability.

Home Health



• Using proper body mechanics to avoid injury• Maintaining a clear walking path• Installation of rails in the home to assist the client as he

or she ambulates• Eliminating throw rugs and cords that cross walking

paths, because they increase the risk of falls• The correct use of assistive devices• Ensuring that all assistive devices are set to the correct

height

Assist the client in obtaining necessary durable medicalequipment (e.g., crutches or walkers).

Refer the client for a home physical therapy consult tohelp maximize his or her ability to safely ambulate athome and to have assistive devices appropriate for thehome environment.

WANDERING

DEFINITION22

Meandering, aimless, and/or repetitive locomotion, fre-quently incongruent with boundaries, limits, or obstaclesthat expose the individual to harm.21


1. Frequent or continuous movement from place to place,often revisiting the same destination(s)

2. Persistent locomotion in search of “missing” or unattain-able persons or places

3. Haphazard locomotion4. Locomotion into unauthorized or private spaces5. Locomotion resulting in unintended leaving of the

premises6. Long periods of locomotion without an apparent desti-

nation7. Inability to locate significant landmarks in a familiar

setting8. Fretful locomotion or pacing9. Locomotion that cannot easily be dissuaded or redi-

rected10. Following behind or shadowing a caregiver’s locomo-

tion


11. Trespassing12. Hyperactivity13. Scanning, seeking, or searching behaviors14. Periods of locomotion interspersed with periods of

nonlocomotion, for example, sitting, standing, orsleeping

15. Getting lost

RELATED FACTORS22

1. Cognitive impairment, specifically memory and recalldeficits, disorientation, poor visuoconstructive (orvisuospatial) ability, language (primarily expressive)defects

2. Cortical atrophy3. Premorbid behavior; for example, outgoing, sociable

personality, premorbid dementia4. Separation from familiar people and places5. Sedation6. Emotional state, especially frustration, anxiety, boredom,

or depression (agitated)7. Physiologic state or need; for example, hunger, thirst,

pain, urination, or constipation8. An over- or understimulating social or physical environ-

ment9. Time of day


1. Dementia2. Neurologic diseases impacting the brain3. Head injuries

4. Medication side effects; for example, analgesics, seda-tives, or hypnotics

5. Hyperthermia


Disturbed Thought ProcessA disturbance in thought processing could well leadto wandering; however, Wandering is a specific physi-cal behavior. Disturbed Thought Process is more spe-cific to cognition.

Impaired MemoryImpaired Memory could also contribute to wandering,but again, Wandering is a specific physical behavior.Impaired Memory refers specifically to the mentalbehavior of remembering.

EXPECTED OUTCOME

Will have decrease in number of episodes of wandering by[date].

Will participate in [number] diversional activities per[day/hour].

Environment will promote client safety (note specificadaptations here, e.g. locked doors, client tracking device)by [date].

TARGET DATESWandering needs to be monitored on a daily basis; however,a target date of 5 days would be appropriate for initial eval-uation of progress.


••••••


Adult Health


Review current medications, both prescription and over-the-counter.

Clear a safe area. Eliminate clutter or other hazards.

Consider the use of weight alarm sensors or othertypes of alert sensors on the bed, chair, or wheel-chair.

Have patient ID in clothes, on a bracelet or necklace, orwallet ID card.

Refer the family to the Alzheimer’s Association SafeReturn Program: (800) 272-3900.

Please refer to the Gerontic Health and Home HealthCare plans for additional nursing actions.

May have adverse effects or interactions.

Safety is the primary concern for patients who maywander.

Alarm will sound when the patient exceeds safety lim-its.98

Assists in identifying the wandering patient.


Wandering 413

••••••

Child Health

This diagnosis, according to its definition and defining characteristics, would not be appropriate for Child Health.

Women’s Health

Interventions for a Women’s Health client with this diagnosis would be the same as the interventions given in Adult Healthand Gerontic Health.

Mental Health

The mental health client with this diagnosis would require the same interventions as those given in Adult Health andGerontic Health.

Gerontic Health

● N O T E : Wandering, a behavior noted in clients with dementia, remains a perplexingactivity for study and nursing interventions. Current research is attempting to describeand design assessments and nursing interventions for various types of wandering behav-ior.94 With this need for further investigation in mind, the following actions are based onkeeping clients safe, providing an outlet for stress and anxiety reduction, and providingenvironmental cues for clients. Nursing interventions should be adapted to meet theneeds of the individual client who wanders. Some clients may favorably respond to inter-ventions such as touch or music, whereas others may not. All clients should be thor-oughly assessed for possible underlying cognitive dysfunction using the Folstein MiniMental State Exam (MMSE) or a similar tool. In addition, a thorough assessment ofthe client’s functional status should be conducted to establish a baseline and safetyprecautions.


Determine the pattern of wandering and share observa-tions with caregivers95 (e.g., the client wanders atcertain times of day or evening, or after visits fromfamily or friends).

Monitor for possible causes of wandering and addressthem as appropriate.Wandering can be caused by envi-ronmental stimuli or a lack of stimuli, feelings of lone-liness or separation, situational insecurity, boredom orfear, sleep disorder, anxiety, or unmet physical needssuch as hunger or pain.

Monitor for expression of intent “I’m going home now”and expression of the loss of a valued adult role, “Thechildren need me now.”

Modify the environment to provide adequate rest, safety,and sleep for the client.

Evaluate the patient’s response to medications and collab-orate with the health-care team to adapt the medicationregimen as needed.

Provide the patient with essential sensory aids (glasses,hearing aids).

Knowledge of patterns can prompt caregivers to antici-pate need for activities or personal attention.

Eliminate possible precipitators of wandering.

Some medications may increase the risk for falls in theclient who wanders.

Prevents possible sensory confusion that can lead to wan-dering and prevents falls when wandering occurs.




••••••


Gerontic Health


Avoid physical and chemical restraints.

Schedule and maintain a regular toileting schedule. [Notethe client’s schedule here.]

Provide information to all staff that a patient is a wan-derer. Develop a mechanism for identification, and aplan to follow if a wanderer is missing. [Note that planhere.]

Use grid like markings in front of doorways.

Ensure that the client has ID bracelet or necklace listinghis or her name and an emergency telephone number.98

Monitor the environment for possible safety hazards (e.g.,toxic solutions or plants, electrical hazards, fire risks,or firearms).99

Have poison control number available in the event ofingestion of unsafe products.

Encourage community-dwelling caregivers to enroll theclient in the Alzheimer’s Association Safe ReturnProgram.

Ensure that there is an updated client photograph avail-able.

Discourage access to exits by using electronic keypadalarm systems on doors.

Depending on care setting, promote group walking activ-ity in early afternoon or after evening meals.100

Based on client preference, use music for 20 to 30 min-utes before periods when the client is known tobecome increasingly agitated.

Incorporate slow-stroke massage for brief periods (10 to20 minutes) to the client’s neck, shoulders, and back inearly morning or late afternoon.

Use familiar items, pictures, and furniture in the client’ssurroundings.

Use distractions such as preferred activities, food, or flu-ids to provide rest periods for the client.

Remove items from environment, such as coats, hats, orkeys, that may trigger wandering.

Disguise doors by painting them the same color as thewall surface.

Place fabric strips attached to door frames or stop signson doors to prevent the client from entering areas thatare “off limits.”

Use pictures and universal symbols for bathrooms, diningareas, or room identification.

These do not stop the urge to wander and may exacerbatethe urge to wander. These measures may contribute toclient injury.

Eliminate possible precipitators of wandering.

Prevention of injury related to wandering.

May prevent the client from exiting due to a change invisual cues.

Provides means of identification if the client becomeslost.

Decreases environmental injury risk.

Decreased cognition may result in the client ingestingtoxic substances.

Provides organized response if the client becomes lost.

Assists in identification efforts. As dementia progresses,there may be marked changes in the client’s appear-ance.

Provides audible alarm if door is opened without usingthe correct code.

Offers outlet for socializing and meeting the client’sactivity and exercise needs.

Music has been shown to reduce or eliminate agitation insome clients affected with dementia.101

Slow-stroke massage has been helpful with some demen-tia clients in reducing the frequency and severity ofagitation and the onset of aggressive behaviors.102

Familiar objects may provide a sense of comfort for theclient.

Clients may not be able to recognize onset of fatiguewhen wandering.

Decreases stimulus for leaving the site.

Difficult for the client to identify as an exit area.

Signs or fabric strips often serve as deterrents to clientswho wander.

Wanderers may no longer have ability to read and inter-pret signs for these areas.


Wheelchair Mobility, Impaired 415

••••••


Arrange furniture areas where clients wander, to encour-age resting spots.

Arrange repetitive activities for the client, such as linenfolding, rocking, or paper work, if the client is engagedin “lapping type wandering” and showing signs offatigue.101

Consider offering food, fluids, toileting, or pain medica-tion when the client initiates wandering episodes, ifthis seems to be a need pattern for the client.103

Provides cues to clients for rest periods.

The client has opportunity for repetitive movement withless energy expended.

Clients with decreased or absent verbal communicationskills may be unable to articulate these basic needs tocaregivers.

Home Health


Consult with and/or refer the patient to assistive resourcessuch as caregiver support groups, as needed.

When wandering is related to inappropriate responses tocues, adapt the environment to change the cues:

• Cover doorknobs.• Remove keys that are in a visible location.• Remove knobs from the oven and stove.

Ensure that the environment is as safe as possible whenwandering occurs:

• Remove knobs from the oven and stove.• Alert neighbors that the client may wander, and inform

them about actions to take when the client is foundwandering.

Provide the client with an ID bracelet indicating numberswhere caregivers can be reached.

Assist the client and caregiver in obtaining alarm systemsto indicate when doors have been opened.

Utilization of existing services is an efficient use ofresources.

May help prevent episodes of wandering and subsequentinjury.

To prevent injury in the event of wandering by the client.

To minimize the time the client is away from caregiversin the event of wandering.

To alert the caregiver if the client begins to wander.

WHEELCHAIR MOBILITY, IMPAIRED

DEFINITION22

Limitation of independent operation of wheelchair withinenvironment.21


1. Impaired ability to operate manual or power wheelchairon even or uneven surface

2. Impaired ability to operate manual or power wheelchairon an incline or decline

3. Impaired ability to operate wheelchair on curbs

RELATED FACTORS22

To be developed.


1. Fracture2. Paralysis

3. Neuromuscular disorders4. Nutritional deficiencies


Impaired Physical MobilityImpaired Wheelchair Mobility could be considered asa subset of Impaired Physical Mobility. Certainly apatient who has Impaired Wheelchair Mobility wouldalso have Impaired Physical Mobility. ImpairedWheelchair Mobility would need to be resolved beforeImpaired Physical Mobility.

Activity IntoleranceIf the patient can tolerate only minimal activitiesbefore having problems, then Activity Intolerancewould be the priority diagnosis. Only after ActivityIntolerance has been resolved would the nurse beable to effectively intervene for Impaired WheelchairMobility.


EXPECTED OUTCOME

Will complete wheelchair mobility training program by[date].

Will demonstrate ability to maneuver wheelchair asnecessary to complete activities of daily living by [date].

TARGET DATES

Resolution of this diagnosis may vary from weeksto months. An appropriate initial evaluation target datewould be 1 to 2 weeks after the date the diagnosis was estab-lished.


••••••


Adult Health


Collaborate with Physical Therapy as needed.

Reinforce instructions from physical therapy.

Assist the patient with strengthening exercises as appro-priate. [Note assistance needed here.]

Assist the patient with functional wheelchair activities asneeded. [Note assistance needed here.]

Facilitate the patient’s participation in his or her own careas much as possible.

To assist in planning activities to improve the patient’sability to independently operate a wheelchair withinthe environment.

Child Health


Determine contributing factors to best consider child’sassistive needs that would facilitate their reachinghighest potential of functioning.

Identify priorities of basic functions (e.g., breathing, air-way maintenance, cardiovascular endurance, toleranceof positioning, proprioception, and neuromuscularcoordination).

Define limitations of tolerance for positioning, move-ment, and ideal plan for mobility.

Determine equipment or assistive equipment needed.

Anticipate safety needs and environmental considerationsrelated to safety needs.

According to maternal and infant or maternal and childdyad or caregiver status, decide who will assist inmobility activities.

Assess for medication implications for movement timingand best potential for desired effects in relation tomobility, freedom of undesired effects, or contraindica-tion of related treatments.

Establish a plan for each 8-hour period to include themaneuvers to be carried out, equipment or personnelneeded, and critical thresholds to be attended to as dic-tated per patient’s status (i.e., pulse oximeter levelabove [specify], pulse range [specify], etc). [Notechild’s plan here.]

A full assessment of contributing factors offers the mostholistic approach to determining the degree of assis-tance needed.

Basic physiologic functioning must be provided for if themovement is to be successful and not bring about alter-ations to basic functions.

Critical thresholds will assist in defining reasonable like-lihood for success.

Stabilization and use of appropriate assistive devices offerlikelihood of success without injury.

Anticipatory safety is inherent in all mobility endeavorsand serves to prevent injury.

Caregiver input serves to put the infant or child at easewith likelihood of success, plus provides an importantopportunity for sense of input by the patient.

The best likelihood for desired effects will be related toappropriate medication correlation, with related mobil-ity or position.

Regular scheduled movement with attention to prescribedassessments, documentation, and awareness of thresh-olds assists in maintaining the client’s stable status.



••••••


Document critical thresholds and report to the physicianas ordered.

Determine outcomes according to previous baseline ordesired level of activity. (May require sub-goals over alonger period of time.) [Note child’s goals here.]

Coordinate mobility activities as necessary with appropri-ate health team members, to include physical therapy,occupational therapy, child life specialist, etc.

Schedule meetings between child/family and others whoare successfully managing mobility issues (as develop-mentally appropriate).

Refer to community agencies and groups that can con-tinue support for client and family. If use of a wheel-chair will be long term, this could include wheelchairsports teams, and adults in the community who aresuccessfully living with similar mobility concerns.

Ongoing assessment and appropriate reporting of criticalthresholds will maintain desired stability of the clientand provide basis for setting limits or increasing limits.

If it takes a period of time more than 3 to 4 days, sub-goals will better reflect the incremental change or grad-ual attainment of a greater goal.

Each person’s input is best utilized in a manner of patient-centered planning to afford optimum likelihood of suc-cess and not tire the patient, vs. fragmented, duplicated,or less than individualized efforts for mobility.

Role modeling significantly enhances learning.

Role modeling enhances learning, and community sup-port enhances self-esteem and decreases sense ofisolation.

Women’s Health


Mental Health


Gerontic Health


Obtain consultation with occupational and physical thera-pists to determine treatment plan for the client.

Check wheelchair for proper fit for the client (adequateseat width, appropriate armrest height, and level offootrests).

Provide positive feedback when the client correctlymanipulates wheelchair.

Ensure environment where the client is active is accessi-ble by wheelchair (e.g., width of door frames, tableheight, ramps, and curb cuts present in walkways).

Promote interdisciplinary communication to ensure thattreatment plan is followed.

Review with the client and/or caregiver teaching plan forwheelchair use.

Occupational and physical therapists are health-care pro-fessionals best suited to evaluate the client and designtreatment regimen.

Proper fit enhances the client’s ability to control wheel-chair.

Positive feedback encourages the desired behavior.

Adapted environment supports wheelchair use.

Clearly described and communicated treatment goalsassist caregivers in providing care and feedback.

Provides opportunities to evaluate learning and addressany questions related to wheelchair use.



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6SLEEP–REST PATTERN1. SLEEP DEPRIVATION 425

2. SLEEP PATTERN, DISTURBED 431

3. SLEEP, READINESS FOR ENHANCED 437


PATTERN DESCRIPTION

The sleep–rest pattern includes relaxation in addition tosleep and rest. The pattern is based on a 24-hour day andlooks specifically at how an individual rates or judges theadequacy of his or her sleep, rest, and relaxation in terms ofboth quantity and quality. The pattern also looks at thepatient’s energy level in relation to the amount of sleep, rest,and relaxation described by the patient as well as any sleepaids the patient uses.

PATTERN ASSESSMENT

1. Does the patient report a problem falling asleep?a. Yes (Disturbed Sleep Pattern)b. No (Readiness for Enhanced Sleep)

2. Does the patient report interrupted sleep?a. Yes (Disturbed Sleep Pattern)b. No (Readiness for Enhanced Sleep)

3. Does the patient report long periods without sleep,resulting in daytime malaise?a. Yes (Sleep Deprivation Pattern)b. No (Readiness for Enhanced Sleep)


A person at rest feels mentally relaxed, free from anxiety,and physically calm. Rest need not imply inactivity, andinactivity does not necessarily afford rest. Rest is a reductionin bodily work that results in the person’s feeling refreshedand with a sense of readiness to perform activities of dailyliving (ADLs).

Sleep is a state of rest that occurs for sustained peri-ods at a deeper level of consciousness. The reduced con-sciousness during sleep provides time for essential repairand recovery of body systems. Sleep is as essential toour bodies as good nutrition and exercise. Sleep is consid-ered one of the major components to our health, perform-ance, safety, and quality of life.1 A person who sleepshas temporarily reduced interaction with the environment.Sleep restores a person’s energy and sense of well-being andlets him or her function in a safe, efficient, and effectivemanner.

Studies have confirmed that sleep is a cyclical phe-nomenon. The most common sleep cycle is the 24-hourday–night cycle. This 24-hour cycle is also referred to asthe Circadian Biological Clock, which regulates the timingof sleep and wakefulness.1,2 In general, light and darknessgovern the 24-hour circadian rhythm. Additional factorsthat influence the sleep–wake cycle of the individual arebiologic, such as hormonal and thermoregulation cycles.Most individuals attempt to synchronize activity withthe demands of modern society. The two specialized areasof the brain that control the cyclical nature of sleep are

the reticular activating system in the brain stem, spinalcord, and cerebral cortex and the bulbar synchronizing por-tion in the medulla. These two systems function intermit-tently by activating and suppressing the higher centers of thebrain.2

After falling asleep, a person passes through a seriesof stages that afford rest and recuperation physically, men-tally, and emotionally. In stage 1, the individual is in arelaxed, dreamy state, and is aware of his or her surround-ings. In stages 2 and 3, there is progression to deeper levelsof sleep in which the individual becomes unaware of his orher surroundings but wakens easily. In stage 4, there is pro-found sleep characterized by little body movement and dif-ficult arousal. Stage 4 restores and allows the body to rest.Stages 1 through 4 are known as non–rapid eye movement(NREM) sleep. NREM sleep accounts for 75 percent of an8-hour night’s sleep. Stage 5 is called rapid eye move-ment (REM) sleep. REM sleep accounts for 25 percent of an8-hour night’s sleep and is the stage in which dreamingoccurs. Other characteristics of REM sleep are irregularpulse, variable blood pressure, muscular twitching, pro-found muscular relaxation, and an increase in gastric secre-tions.2,3 After REM sleep, the individual progresses backthrough stages 1, 2, and 3 again.

Sleep patterns and characteristics vary and changeover the life cycle. A person’s age, general health status, cul-ture, and emotional well-being dictate the amount of sleephe or she requires. On the whole, older persons require lesssleep, whereas young infants require the most sleep. As thenurse assesses the patient’s needs for sleep and rest, he orshe makes every effort to individualize the care according tothis sleep–rest cycle. A major emphasis is to provide patienteducation regarding the influence of disease process onsleep–rest patterns.

Reports of the occurrence of excessive and pathologicsleep most commonly relate to narcolepsy and hypersom-nia.2,3 Narcolepsy is characterized by an attack of irresistiblesleep of brief duration with “auxiliary” symptoms. In sleepparalysis, the narcoleptic patient is unable to speak or moveand breathes in a shallow manner. Auditory or visual hypn-agogic hallucinations may occur. Cataplexy, a brief form ofnarcolepsy, is an abrupt and reversible decrease or loss ofmuscle tone and is most often elicited by emotion. Theattacks may last several seconds and almost go undetected,or they may last as long as 30 minutes with muscular weak-ness being evident. In the initial stage of the attack, con-sciousness remains intact.2,3

Hypersomnia, in contrast, is characterized by daytimesleepiness and sleep states that are less imperative and oflonger duration than those in narcolepsy. Often, a deepeningand lengthening of night sleep is also noted. Sleep apnea andthe Kleine–Levin syndrome are two examples of the hyper-somnia disorders.2,3

Sleep apnea may occur in patients with a damagedrespiratory center in the brain, brain stem infarction, drug

422 Sleep–Rest Pattern

••••••


intoxication (barbiturates, tranquilizers, etc.), bilateral cor-dotomy, and/or Ondine’s curse syndrome. Patients with thetypical pickwickian syndrome show marked obesity andassociated alveolar hypoventilation, sleep apnea, and hyper-somnia. Several forms of this condition may exist withoutobesity. One such syndrome is Ondine’s curse syndrome,which involves the loss of the automaticity of breathing andmanifests during sleep as a recurrent apnea. Another is theKleine–Levin syndrome, which is associated with periods ofhypersomnia accompanied by bulimia or polyphagia andmental disturbances. A cyclic hypersomnia is also reportedthat is related to the premenstrual periods. The typical syn-drome—pickwickian—is rare, whereas the atypical variantsseem more common.3

Various factors influence a person’s capability togain adequate rest and sleep.4,5 For the home setting, it isappropriate for the nurse to assist the patient in developingbehavior conducive to rest and relaxation. In a health-care setting, the nurse must be able to provide ways of pro-moting rest and relaxation in a stressful environment. Lossof privacy, unfamiliar noises, frequent examinations, tiringprocedures, and a general upset in daily routines culmi-nate in a threat to the client’s achievement of essential restand sleep.


In general, as age increases, the amount of sleep per nightdecreases. The length of each sleep cycle—active (REM)and quiet (NREM)—changes with age. For adults, there isno particular change in the actual number of hours slept, butthere is a change in the amount of deep sleep and light sleep.As a person ages, the amount of deep sleep decreases andthe amount of light sleep increases. This helps explain whythe older patient wakens more easily and spends time insleep throughout the day and night. REM sleep decreases inamount from the time of infancy (50 percent) to late adult-hood (15 percent). The changes in sleep pattern with agedevelopment are7:

Infant: Awake 7 hours; NREM sleep, 8.5 hours; REMsleep, 8.5 hours

Age 1: Awake 13 hours; NREM sleep, 7 hours; REMsleep, 4 hours



Age 75: Awake 17 hours; NREM sleep, 6 hours; REMsleep, 1 hour

INFANT

The development of sleep and wakefulness can be traced tointrauterine life. A gestational age of 36 weeks seems to be

a landmark, for it is at this time that the behavioral states inthe fetus and preterm infant begin to take on a more maturecharacter. The joining of physiologic variables results inidentification of recurrent behavioral states with variousparameters. Term birth leads to a number of profoundchanges, especially in respiratory regulation, but more evi-dence suggests that continuity of development, rather thandiscontinuity, prevails.7

The newborn begins life with a regular schedule ofsleep and activity that is evident during periods of reactivity.For the first hour, infants born of unmedicated mothersspend 60 percent of the time in the quiet, alert state and only10 percent of the time in the irritable, crying states. Six dis-tinct sleep–activity states for the infant have been noted: (1)deep sleep, (2) light sleep, (3) drowsiness, (4) quiet alert, (5)active alert, and (6) crying.7,8

After 1 month of age, sleep and wakefulness changedramatically, as do a large number of physiologic variables.This period of central nervous system (CNS) reorganization(with a likely increased vulnerability) is immediately fol-lowed by a short transient interval at 3 months of age inwhich play and wakefulness—and, within it, the basicrest–activity cycle–show excessive regularity. This regular-ity may carry its own risk.

The study of mobility has proved worthwhile indetecting the origin of the basic rest–activity cycle in thefetus. Neonatologists, who deal with the immature infant,often use mobility in prognosis.

Apneas during sleep are common in normal infantsand occur most often during the newborn period, with amarked decrease in the first 6 months of life. Long apneas,lasting longer than 15 seconds, are not usually observed dur-ing sleep in laboratory conditions. Obstructive apneas of 6to 10 seconds are also rarely observed. However, in labora-tory studies, paradoxical breathing is observed in neonates,and periodic breathing is associated with REM sleep in nor-mal infants.7,9

Infants found not breathing by parents are usuallyrushed to the hospital. Causes for life-threatening apnea tobe investigated include congenital conditions, especiallycardiac disease or arrhythmias; cranial, facial, or other con-ditions affecting the anatomy of the airway; infections suchas sepsis, meningitis, pneumonia, botulism, and pertussis;viral infections such as respiratory syncytial virus; meta-bolic abnormalities; administration of sedatives; seizures;and chronic hypoxia. If these causes are ruled out, the infantis diagnosed as having “apnea of infancy.” Sleep studies,with polygraph recordings, are required. The term near-misssudden infant death syndrome (near-miss SIDS) implies thechild is found limp, cyanotic, and not breathing and wouldhave died had caretakers not intervened. Because the rela-tionship of the near miss SIDS event to SIDS is speculative,apnea of infancy is the preferred term.9,10

Obstructive and central apnea identification, hypop-nea, prolonged expiration, apnea and reflux, and apnea and


••••••


cardiac arrhythmia are the current issues being studiedin trying to solve this problem. For any infant-relatedapnea, hospitalization, with special observation for all pos-sible contributing factors and close monitoring of cardiacand respiratory function, is recommended. Attention mustbe given to parents for the extreme anxiety this problemcreates.

The newborn and young infant spends more time inREM sleep than adults do. As the infant’s nervous systemdevelops, the infant will have longer periods of sleep andwakefulness that become more regular. At approximately8 months of age, the infant goes through the stage of sepa-ration anxiety with potentially altered sleep patterns.Teething, ear infections, or other disorders affect sleep pat-terns. Respirations are quiet, with minimal activity notedduring deep sleep. The infant sleeps an average of 12 to 16hours per day.


The toddler needs approximately 10 to 12 hours of sleep atnight, with an approximate 2-hour nap in the afternoon. Thepercentage of REM sleep is 25 percent. Rituals for prepara-tion for sleep are important, with bedtime associated as sep-aration from family and fun. Quiet time to graduallyunwind, a favorite object for security, and a relatively con-sistent bedtime are suggested. Nightmares may begin tooccur because of magical thinking.

The preschooler sleeps approximately 10 to 12 hoursper day. Dreams and nightmares may occur at this time,and resistance to bedtime rituals is also common. Unwind-ing or slowing down from the many activities of the dayis recommended to lessen sleep disturbances. Actualattempts to foster relaxation by mental imaging at this agehave proved successful. The percentage of REM sleep is 20percent.

Special needs may be prompted for the toddler duringhospitalization. When at all possible, a parent’s presenceshould be encouraged throughout nighttime to lessen fears.Limit-setting with safety in mind is also necessary for thetoddler because of his or her surplus of energy and the desirefor constant activity. The preschooler may be at risk forfatigue. Sleep may not be necessary at naptime, but restwithout disturbance is recommended to supplement nightsleep and to prevent fatigue.

SCHOOL-AGE CHILD

The school-age child seems to do well without a nap andrequires approximately 10 hours of sleep per day, withREM sleep being approximately 18.5 percent. Individual-ized rest needs are developed by this age, with a reliablesource being the child who can express his or her feelingsabout rest or sleep. Health status would also determine to a

great extent how much sleep the child at this age requires.Permission to stay up late must be weighed against thepotential upset to routine and demands of the next day.When bedtime is assigned a status, peer pressure and powerissues may ensue.

When the school-age child alters the usual routines ofsleep and rest, fatigue may result. Attempts should be madeto maintain usual routines even when school is not in sessionto best maintain the usual sleep–rest pattern.

ADOLESCENT

Irregular sleep patterns seem to be the norm for the adoles-cent as a result of high activity levels and usual peer-relatedactivities. There may be a tendency to overexertion, which ismade more pronounced by the numerous physiologicchanges that create increased demands on the body. Fatiguemay occur during this time. On average, the adolescentsleeps approximately 8 to 10 hours per day, with REM sleepcomprising 20 percent.

Rest may be necessary to supplement sleep. Supple-menting sleep with rest serves to assist in preventing illnessor the risk of illness. Extracurricular activities may also needto be prioritized.

ADULT

An adult sleeps approximately 8 hours per day, with REMsleep comprising 22 percent. Sleep patterns may be subjectto the demands of young infants or children in the householdor after-hours professional and social activities.

The adult may be at high risk for fatigue because ofincreasing role expectations, especially in caring for a newbaby. Sleep deprivation can adversely affect the ability tocope with the many expectations the adult may feel.

Research has shown that women of all ages havehigher rates of sleep disturbance than men do. Some specu-lation has occurred that relates this to the reproductivelives of women and hormonal changes. It is well docu-mented that the psychosocial and hormonal changes thataccompany pregnancy lead to sleep disturbances.6 Thatsleep deprivation occurs during the postpartum period isa well-known fact. A new baby does not allow a motheruninterrupted sleep for approximately 4 to 6 weeks afterbirth.8,11,12

Sleep disturbance seen in women who are experienc-ing perimenopausal and menopausal symptoms is oftenrelated to declining estrogen levels. “Disrupted sleep is oneof the earliest effects on the brain of decreasing levels ofestrogen.”11 Sometimes these sleep changes begin as earlyas 8 to 10 years before menses cease, and research hasproved that sleep deprivation not only causes suppression ofthe immune system but is also a major factor in causing per-sistent fatigue.


••••••


OLDER ADULT

As adults age, they are more likely to report sleeping diffi-culties. As many as 50 percent of people age 65 and oldercomplain of sleep problems on a regular basis. Complaintsoften include sleeping less, frequent nighttime awaken-ing, waking too early in the morning, and napping in thedaytime.13,14 The proportion of REM sleep may vary from20 to 25 percent; however, deep sleep (stage 4 NREM sleep)is decreased. There is no clinical evidence showing thatolder adults require less sleep, but evidence exists show-ing that older adults sleep less and sleep less well.15

Obstructive sleep apnea, periodic limb movement disorder,and restless leg syndrome are common sleep disorders foundin the older population.16 Circadian rhythm changes withaging can cause changes in the older adult’s sleep–wakecycle that result in poor nighttime sleep and increased day-time napping.

Sleep pattern disturbances in the elderly may occur asa result of undiagnosed depression or medication-inducedsleep problems. Other risk factors interfering with sleep mayinclude unrelieved pain, alcohol use, lack of daytime activ-ity, nocturia, or medical conditions such as dementia.17

Older adults involved in caregiving for people with demen-tia are at risk for developing sleep deprivation as the demen-tia progresses.2,3,18 Institutionalized older adults may reportproblems with sleeping if their usual sleep pattern does notcoincide with the facility schedule.

Individualized attention to sleep and potential fatigueis critical to prevent further decreases in activity and changesin self-worth for older adults. Fatigue plays a major role indetermining the quality and amount of musculoskeletalactivity engaged in by the elderly. Poor sleep may affectrehabilitation potential, alertness, safety, and psychologicalcomfort. Examining factors that may influence fatigue is anessential part of the assessment for the sleep–rest pattern.

Sleep Deprivation 425

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T A B L E 6 . 1 NANDA, NIC, and NOC Taxonomic Linkages


Sleep–rest Pattern Sleep Enhancement

Sleep Enhancement


Sleep Deprivation

Sleep Pattern, Disturbed

Sleep, Readiness for Enhanced

ConcentrationMood EquilibriumSleepRestMood EquilibriumPerson Well-beingSleepRestWell-BeingComfort LevelPain ControlRestSleep


SLEEP DEPRIVATION

DEFINITION

Prolonged periods of time without sleep (sustained, natural,periodic suspension of relative consciousness).19


1. Daytime drowsiness2. Decreased ability to function3. Malaise4. Tiredness5. Lethargy6. Restlessness7. Irritability8. Heightened sensitivity to pain9. Listlessness

10. Apathy11. Slowed reaction12. Inability to concentrate13. Perceptual disorders (e.g., disturbed body sensation,

delusions, and feeling afloat)14. Hallucinations15. Acute confusion16. Transient paranoia17. Agitated or combative18. Anxious19. Mild, fleeting nystagmus20. Hand tremors

RELATED FACTORS19

1. Prolonged physical discomfort2. Prolonged psychological discomfort



••••••

3. Sustained inadequate sleep hygiene4. Prolonged use of pharmacologic or dietary antiso-

porifics5. Aging-related sleep stage shifts6. Sustained circadian asynchrony7. Inadequate daytime activity8. Sustained environmental stimulation9. Sustained unfamiliar or uncomfortable sleep environ-

ment10. Non–sleep-inducing parenting practices11. Sleep apnea12. Periodic limb movement (e.g., restless leg syndrome

and nocturnal myoclonus)13. Sundowner’s syndrome14. Narcolepsy15. Idiopathic central nervous system hypersomnolence16. Sleepwalking17. Sleep terror18. Sleep-related enuresis19. Nightmares20. Familial sleep paralysis21. Sleep-related painful erections22. Dementia


1. Colic2. Hyperthyroidism3. Anxiety4. Chronic obstructive pulmonary disease5. Pregnancy; postpartum period6. Pain7. Alzheimer’s disease


Ineffective Individual CopingPatients sometimes use sleep as an avoidance mech-anism and will report “not getting enough sleep” whenin fact there is no sleep deprivation. A review of thenumber of hours of sleep would indicate the patient isgetting a sufficient amount of sleep.

FatigueThe patient will talk about lack of energy and difficultyin maintaining his or her usual activities. However,assessment documents that this fatigue exists regard-less of the amount of sleep.

Disturbed Sleep PatternSleep Deprivation refers specifically to a decreasedamount of sleep; Disturbed Sleep Pattern refers tomultiple problems with sleeping. Disturbed SleepPattern could, if not resolved, result in SleepDeprivation.

EXPECTED OUTCOME

Will sleep, uninterrupted, for at least 6 to 8 hours per nightby [date].

● N O T E : The actual hours of uninterrupted sleep willdepend on the patient’s age and developmental level.

TARGET DATES

The suggested target date is no less than 2 days after the dateof the diagnosis and no more than 5 days. This length oftime will allow for initial modification of the sleep pattern.


Adult Health


Avoid coffee or cola, which contain caffeine, from lateafternoon on.

Avoid over-the-counter pain relievers that containcaffeine from late afternoon on.

Avoid cold medicines that contain pseudoephedrineand phenylpropanolamine from late afternoon on.

Avoid alcohol at night.

Adjust the timing of diuretics to avoid nighttime tripsto the bathroom.

Check for other prescription drugs taken to determinewhether they may interfere with sleep patterns(e.g., antidepressants, thyroid medication, etc.)

Avoid eating a heavy meal late at night. However, asmall snack such as warm milk or chamomile teamay be relaxing.

Caffeine is a stimulant that interferes with sleep.

Pseudoephedrine and phenylpropanolamine as well asother adrenergics act as stimulants.20,22

Alcohol interferes with substances in the brain that allowfor continuous sleep.22

Waking to go to the bathroom will interfere with sleep.

Side effects of some prescriptions include sleep patterndisturbances.

Heavy meals increase stomach acid and intestinal stimu-lation. A light snack may allay hunger pains.20



••••••


Consider herbal solutions such as valerian. However,watch for side effects such as headaches, nausea,blurred vision, heart palpitations, and paradoxically,excitability and restlessness. Do not take concurrentlywith other sleep aids or alcohol.

Assess the patient’s mattress and pillow. Is it too hard orsoft? Does it offer enough support?

Check for mild iron deficiency. Vitamin E may also helpwith restless leg syndrome.

Teach the patient to try relaxation techniques such asmeditation, counting your breaths, slowly tensing andrelaxing muscles, guided imagery, etc. just beforebedtime.

Encourage the patient to exercise earlier in the day ratherthan at night.

Counsel the patient to not “take problems to bed.” He orshe should sit quietly in a chair for a few minutesbefore going to bed and think about all those thingsthat have worried him or her during the day.

Reduces the time it takes to get to sleep but does notseem to reduce the number of times people wake in thenight.

The mattress is an important component of restful sleep.

Even a low–normal iron level may cause restless leg syn-drome.

Exercise stimulates the body.

Helps clear the patient’s mind, order his or her problems,and set his or her plans for the next day.20

Child Health


Determine all possible contributing factors that mayimpact sleep deprivation (including situational,environmental, or those related to another medicalcondition).

Stabilize factors that can be stabilized to minimize con-tributing factors*:

• Clustering activities to not disturb unnecessarily.• Providing as near to normal routine for sleep for the

client, with attention to developmental needs (as notedin under Conceptual Information).

Consider reassessment on an ongoing basis for disruptivecontributing factors.

Based on assessments, develop a restructured plan forsleep allowance by eliminating, to degree possible, allfactors identified to be barriers to sleep.

Determine teaching needs of the client, parents, and/orcaregivers.

Reevaluate measures to define the optimum likelihood forsleep to occur as desired.

Implement appropriate nursing measures as noted forsleep disturbance as applicable.

Monitor for caregiver frustration in attempts to deal withsleep deprivation secondary to caregiver role strain.

Provides a database for individualization of care.

Affords a better picture of actual causative factors forsleep deprivation with attention to anticipatory needs.

In a short period of time there may be significant changesto consider for accurate sleep assessment.

Restructuring may afford sleep and awake cycles to recur.

Specific knowledge regarding sleeping and waking cyclesfacilitates individualized match of needs for clients andcaregivers.7,8

Possible growth and developmental phases may berequired for appropriate reestablishment of cycles.

Once major factors are stabilized, basic maneuvers toencourage sleep may be afforded per prior successfulplan with allowance for updated developmental needs.

Parents will often be subject to sleep deprivation of theinfant or child.




••••••


Child Health


Assist the parents in identification of ways to deal withsleep deprivation of the infant or child.

Reassure the parents or, if applicable, the child, of thelikelihood for regular sleep pattern to be reestablishedwith sufficient time and allowance for recycling.

Determine effect sleep deprivation may have over time,monitoring every 8 hours to note related alterations,with attention to basic physiologic parameters as indi-cated per the client’s condition and needs.

Monitor for mental and cognitive capacity, with attentionto subjective or behavioral changes.

Ensure safety needs are met at all times.

Empowerment for possible solutions offers growth poten-tial as parents and acknowledges potential need ofcaregiver.7,24

Ability to cope with problem is increased when individu-als believe problem is manageable.

Related physiologic alterations often ensue related tosleep deprivation.

Identification of related onset of interference in usualmental or behavioral domain will help minimizegreater disturbance of the client’s status.

Altered sleep and wake cycles may alter usual proprio-ception or cognitive ability.7,24

*In instances of nightmares, offer safety and reassurance to child.

Women’s Health

Nursing actions for the Women’s Health client with this diagnosis are the same as those actions for Adult Health with thefollowing exceptions:


Assess the client for feelings of sleepiness or drowsinessduring the day.

If the client is reporting perimenopausal symptoms anddisturbances in memory at any age, but particularly inthe 30s, 40s, and 50s, refer to the physician for hor-monal evaluation.12

Provide the patient/client with suggestions to adapt to thenewborn infant’s sleep–wake cycle during the first 2 to4 weeks postpartum:

• Turn off pagers and phones during sleep times.• Rest and/or sleep when the baby sleeps.

Plan with the partner to take turns during the night to getthe baby (partner can bring the baby to the mother forbreastfeeding, which helps the mother to fall asleepagain faster).

Disruptive sleep patterns can lead to problems withmemory and are associated with daytime drowsiness,fatigue, feeling “foggy” mentally along with distur-bances in memory, concentration, and libido.

As estrogen levels drop, the brain responds with bursts ofadrenalin-type chemicals that arouse one from sleep.Prolonged periods of sleep disruption can be a causeof biochemical changes, which can lead to chronicfatigue and depression.11,12

Research has shown that the most critical period for sleepdisturbance is the first 2 to 6 weeks postpartum. If thenew mother does not experience some relief and assis-tance, it could very easily lead to sleep deprivation,chronic fatigue, and depression.8,25

Mental Health


Collaborate with the physician and pharmacist to assessfor physiologic and pharmacologic factors that con-tribute to wakefulness.

Sleep disorders, such as sleep apnea, and certain medicalconditions can contribute to sleep deprivation by dis-ruption of normal sleep patterns.26–28



••••••


Assess the client’s use of caffeine, alcohol, tobacco, andother substances. (This can be accomplished with asleep journal.)

Assess the client for changes in normal activity patterns.(This can be accomplished with a sleep journal.)

Sit with the client for [number] minutes each shift to dis-cuss current stressors.

Spend 30 minutes each shift in the first 24 hours toreview with the client the strategies he or she has usedto improve sleep. Validate and normalize the client’sresponses. [Note persons responsible for this here.]

Develop with the client a plan to limit caffeine-containingbeverages and nicotine 4 hours before bedtime. [Notethat plan here.]

Develop with the client a plan for positive reinforcementfor accomplishing the goals established. [Note thebehaviors to reward and the rewards here.]

Develop an exercise schedule. [Note schedule and type ofexercise here.] Arrange schedule so the client is notexercising just before bedtime.

Spend [number] minutes [times a day] assisting the clientwith problem solving at least 2 hours before bedtime.

Establish a bedtime routine with the client. [Note theclient’s routine here.]

Provide a light, high-carbohydrate snack before bedtime.[Note the client’s preference here.]

Use of certain chemicals can contribute to sleep distur-bance by increasing central nervous system stimula-tion.28

Changes in environmental conditions can contribute tosleep disturbance. Exercise close to bedtime can causestimulation and make it difficult to begin sleep.Irregular daily cycles can interfere with sleep patterns.Also, the client’s perceived sleep time may differ fromthe actual time.28

Emotional stressors can increase anxiety and decrease theclient’s ability to relax sufficiently to sleep normally.27

Understanding the client’s perception of the situation ofpast solutions facilitates change. Decreases feelings ofisolation and creates the perception of a manageableproblem.20,21

Caffeine and nicotine stimulate the central nervous sys-tem.28

Positive reinforcement strengthens desired behaviors.28

Exercise promotes normal daytime fatigue and facilitatesnormal sleep patterns.

Concerns not addressed in a constructive manner cancontribute to nighttime wakefulness. Stress beforebedtime can inhibit normal sleep.31

Routine promotes relaxation.28

Hunger can interfere with normal sleep patterns. Carbo-hydrates increase tryptophan, which facilitates thedevelopment of serotonin. Serotonin promotes sleep.28

Gerontic Health


Teach the older adult or caregiver to maintain his or herdaily schedule of rising, resting, and sleeping.

Encourage the older adult to use progressive musclerelaxation as a strategy to promote sleep.

Provide caregivers with information on community re-sources, stress management, and ways to reduce disrup-tive behaviors when caring for people with dementia.

Consult with the physician for possible evaluation ofsleep disorder.

Avoid further changes in circadian rhythm.

Progressive muscle relaxation has been found to be aneffective nonpharmacologic intervention to improvesleep onset and quality in older adults.32

Assists caregivers in reducing sense of isolation andstress.18

Because sleep problems are assumed to be normal agingby elderly and health-care professionals, sleep disor-ders are often not evaluated or treated.13




••••••



● N O T E : The Adult Health interventions also apply to the Home Health/CommunityHealth client with the following additions:


Maintain client safety:• Ensure that the client does not attempt to drive while

sleep deprived.• Ensure that the client does not try to cook while sleep

deprived.• Ensure that the caregiver is not sleep deprived while

trying to care for the patient or administering medi-cations.

Reinforce in writing any client education that occurswhile the client is sleep deprived.

Manage pain quickly and effectively.

Identify predisposing factors. Eliminate identified factorsthat contribute to the present sleep deprivation and/orthat place the client at risk for exacerbation of existingproblems:

• Pain or other symptoms that are not properly managed• Environmental disturbances, such as outside lights or

noises• Frequent interruptions during normal sleep times

Assess the client’s emotional stressors and provide refer-rals as needed for counseling or other communityresources, such as support groups.

The use of prescription or over-the-counter medications,such as the following, may disrupt sleep:

• Hypnotics• Diuretics• Antidepressants and stimulants• Alcohol• Caffeine• Beta-adrenergic blockers• Benzodiazepines• Narcotics• Anticonvulsants

Assist the client/family in modifying the home environ-ment to facilitate effective sleep patterns:

• Good ventilation• Quality mattress• Quiet sleep environment or soft “white” noise, if

preferred• Dark sleep environment with soft night lights, if

preferred• Where possible, the bedroom should be used for

sleeping only.• Work, television viewing, studying, and other

activities should be done in other rooms.


Ensures that the content is available for review as needed.

Pain can contribute to further sleep deprivation, and theclient experiences a heightened sensation of pain whensleep deprived.

To facilitate effective sleep patterns


Sleep Pattern, Disturbed 431

••••••

Assist the client/family in developing an activity plan tofacilitate effective sleep patterns:

• Exercise 2 or more hours before bedtime.• Engage in enjoyable exercise.• Avoid excess fatigue.• Avoid excess sleep on weekends or holidays to prevent

alterations in the normal sleep cycle.

Assist the client/family in developing an eating/diet planto facilitate effective sleep patterns:

• Avoid large, heavy meals at night.• Avoid caffeine in the evening.• Identify food allergies and avoid allergens.• Maintain a normal, healthy body weight.

Encourage self-care, exercise, and activity, as appropriate,based on medical diagnosis and client condition.



Sleep and rest patterns are stabilized by a balanceof activity and exercise.


SLEEP PATTERN, DISTURBED

DEFINITION19

Time-limited disruption of sleep (natural, periodic suspen-sion of consciousness) amount and quality.


1. Prolonged awakenings2. Sleep maintenance insomnia3. Self-induced impairment of normal pattern4. Sleep onset longer than 30 minutes5. Early morning insomnia6. Awakening earlier or later than desired7. Verbal complaints of difficulty falling asleep8. Verbal complaints of not feeling well rested9. Increased proportion of stage one sleep

10. Dissatisfaction with sleep11. Less than age-normal total sleep time12. Three or more nighttime awakenings13. Decreased proportion of stages three and four sleep

(e.g., hyporesponsiveness, excess sleepiness, anddecreased motivation)

14. Decreased proportion of REM sleep (e.g., REMrebound, hyperactivity, emotional lability, agitation andimpulsivity, and atypical polysomnographic features)

15. Decreased ability to function

RELATED FACTORS19

1. Psychologicala. Ruminative presleep thoughtsb. Daytime activity patternc. Thinking about homed. Body temperaturee. Temperament

f. Dietaryg. Childhood onseth. Inadequate sleep hygienei. Sustained use of antisleep agentsj. Circadian asynchronyk. Frequent changing sleep–wake schedulel. Depression

m. Lonelinessn. Frequent travel across time zoneso. Daylight or darkness exposurep. Griefq. Anticipationr. Shift works. Delayed or advanced sleep phase syndromet. Loss of sleep partner, life changeu. Preoccupation with trying to sleepv. Periodic gender-related hormonal shiftsw. Biochemical agentsx. Feary. Separation from significant othersz. Social schedule inconsistent with chronotype

aa. Aging-related sleep shiftsbb. Anxietycc. Medicationsdd. Fear of insomniaee. Maladaptive conditioned wakefulnessff. Fatiguegg. Boredom

2. Environmentala. Noiseb. Unfamiliar sleep furnishingsc. Ambient temperature, humidityd. Lightinge. Other-generated awakeningf. Excessive stimulation



••••••


Adult Health


Teach relaxation exercises as needed.

Suggest sleep-preparatory activities, such as quiet music,warm fluids, and decreased active exercise at least 1hour before scheduled sleep time. Provide a high-carbohydrate snack.

Provide warm, noncaffeinated fluids after 6 P.M.; limitfluids after 8 P.M.

Assist to bathroom or bedside commode, or offer bedpanat 9 P.M.

Schedule all patient therapeutics before 9 P.M.

Maintain room temperature at 68 to 72�F.

Notify operator to hold telephone calls starting at 9 P.M.

Ensure adherence, as closely as possible, to the patient’susual bedtime routine.

Close door to room; and limit traffic into room beginningat least 1 hour before scheduled sleep time.

Administer required medication (e.g., analgesics or seda-tives, after all daily activities and therapeutics are com-pleted). Monitor effectiveness of medication 30minutes after time of administration.

Give a back massage immediately after administeringmedication. If no medications are needed, give backmassage after toileting.

Place the patient in preferred sleeping position; supportposition with pillows.

Ascertain whether the patient would like a night light.

Decreases sympathetic response and decreases stress.

These winding-down activities promote sleep.Carbohydrates stimulate secretion of insulin. Insulindecreases all amino acids but tryptophan. Tryptophanin larger quantities in the brain increases production ofserotonin, a neurotransmitter that induces sleep.1,33

Warm drinks are relaxing. Limiting fluid reduces thechance of mid-sleep interruption to go to the bathroom.

The urge to void may interrupt the sleep cycle during thenight. Voiding immediately before going to bed lessensthe probability of this occurring.

Promotes uninterrupted sleep.

Environment temperature that is the most conducive tosleep.


Follows the patient’s established pattern; promotes com-fort and allows the patient to wind down.

Reduces environmental stimuli.5

Promotes action and effect of medication; allows evalua-tion of medication effectiveness; and provides data forsuggesting changes in medication, if needed.

Relaxes muscles and promotes sleep.

Promotes the patient’s comfort, and follows the patient’susual routine.

Promotes sense of orientation in an unfamiliar environment.

g. Physical restrainth. Lack of sleep privacy or controli. Nurse for therapeutics, monitoring, or laboratory testsj. Sleep partnerk. Noxious odors

3. Parentala. Mother’s sleep–wake patternb. Parent–infant interactionc. Mother’s emotional support

4. Physiologica. Urinary urgencyb. Wetc. Feverd. Nauseae. Stasis of secretionsf. Shortness of breathg. Positionh. Gastroesophageal reflux


1. Colic2. Hyperthyroidism3. Anxiety4. Depression5. Chronic obstructive pulmonary disease6. Any postoperative state7. Pregnancy; postpartum period

EXPECTED OUTCOME

Will verbalize decreased number of complaints regardingloss of sleep by [date].

TARGET DATES

The suggested target date is no less than 2 days after the dateof diagnosis and no more than 5 days. This length of timewill allow for initial modification of the sleep pattern.



••••••

Child Health


Give a warm bath 30 minutes to 1 hour before scheduledsleep time.

Feed formula, or a snack of protein and simple carbohy-drate (no fats), 15 to 30 minutes before scheduledsleep time.

Implement usual bedtime routine:• Rocking• Patting• Child cuddling with favorite stuffed animal• Using special blanket

Read a calm, quiet story to the child immediately afterputting to bed.

Provide environment conducive to sleep, such as:• Room temperature of 74 to 78�F• Soft, relaxing music• Night light

Restrict loud physical activity at least 2 to 3 hours beforescheduled sleep time.

Schedule therapeutics around sleep needs. Complete alltherapeutics at least 1 hour before scheduled sleep time.

Assist the parents with defining and standardizing ageneral waking and sleeping schedule.

Teach the parents and child appropriate, age-relatedrelaxation techniques (e.g., imagination of the “mostquiet place game” and other imaging techniques).

Discuss with the parents the difference between inabilityto sleep and fears related to developmental crises:

• Infant and toddler—Separation anxiety• Preschooler—Fantasy versus reality• School-age—Ability to perform at expected levels• Adolescent—Role identity versus role diffusion

Ensure the child’s safety according to developmental andpsychomotor abilities (e.g., infant placed on side orback; no plastic, loose-fitting sheets; and bedrails toprevent falling out of bed).

Promotes relaxation, and provides quiet time as a part ofthe sleep routine.

In young infants and small children, a sense of fullnessand satiety, without difficulty in digestion, promotessleep without the likelihood of upset or disturbances.

A structured approach to setting limits while honoringindividual preference. Provides security and promotessleep.

Reading allows a passive, meaningful enjoyment thatoccupies the attention of the young child while creat-ing a bond between the caretaker and child.Serendipitous relaxation often follows.

Lack of unpleasant stimuli will provide sensory rest,as well as a chance to tune out need for cognitive–perceptual activity.

Overstimulating physical activity may signal the centralnervous system to activate bodily functions.

The nurse’s valuing of the sleep schedule will convey resp-ect for the importance of sleep to the patient and family.

Parents will be able to cope better with developmentalissues given the knowledge and opportunity to inquireabout sleep-related issues. It is reported that limit set-ting with confidence by parents is the most effectiveway to develop healthy patterns of sleep when norelated health problems exist.

Improves parents’ coping skills in dealing with commondevelopmental issues that affect sleep.

Basic safety standards for infants and children.


Once the patient is sleeping, place a “do not disturb” signon the door.

Increase exercise and activity during day as appropriatefor the patient’s condition.

When appropriate, discuss reasons for the sleep patterndisturbance and teach appropriate coping mechanisms.


Promotes a regular diurnal rhythm.

Promotes adaptation that can increase sleep.




••••••


Women’s Health


Knowledge and proper planning can help the patientreduce fatigue during pregnancy and the immediatepostpartum period.8,34

Knowledge of life changes can help in planning andimplementing mechanisms to reduce fatigue and sleepdisturbance.

During the immediate postpartum period, 2 to 4 weeksafter birth, it is important for the mother to adjust hersleep cycle to the infant’s if at all possible, in order toget enough rest and sleep.8

During perimenopause and menopause try such things asavoiding caffeine, alcohol, and nicotine; and exercis-ing, but not too close to bedtime. About an hour beforegoing to bed engage in a relaxing, nonalerting activity,do not drink or eat too much, and maintain a quiet,dark, and preferably cool but comfortable, sleep envi-ronment.1,12

For women in midlife, restless sleep with several awaken-ings may be one of the earliest indicators of decliningestrogen. Sleep apnea can lead to sexual dysfunction,major depression, high blood pressure, chronic fatigue,problems with memory and concentration during theday, and potentially a heart attack.11,12

Assist the patient in scheduling rest breaks throughoutday.

Review daily schedule with the patient, and assist thepatient to adjust her sleep schedule to coincide with theinfant’s sleep pattern.

Identify a support system that can assist the patient inalleviating fatigue.

Assist the patient in identifying lifestyle adjustments thatmay be needed because of changes in physiologicfunction or needs during experiential phases of life(e.g., pregnancy, postpartum, or menopause):

• Possible lowering of room temperature• Layering of blankets or covers that can be discarded or

added as necessary• Practicing relaxation immediately before scheduled

sleep time• Establishing a bedtime routine (e.g., bath, food, fluids,

or activity)

Involve significant others in discussion and problem-solving activities regarding life-cycle changes that areaffecting work habits and interpersonal relationships(e.g., hot flashes, pregnancy, or postpartum fatigue).

Teach the patient to experiment with restful activitieswhen she cannot sleep at night rather than lying in bedand thinking about not sleeping.

Discuss with women the following to assess sleep patterndisturbance:

• Do they have an irregular sleep–wake pattern?• Do they have problems falling asleep at night?• Do they regularly wake up several times at night and

have difficulty falling back asleep?• Do they feel sleepy or drowsy during the day?

Assess for snoring, jerky movements during sleep, orstoppage of breathing during sleep. (Can assess insleep lab or question the client’s sleeping partner.)

Collaborate with the woman’s physician, and recommendan evaluation of hormone levels and/or further evalua-tion of sleep disorders.



••••••

Mental HealthA C T I O N S / I N T E R V E N T I O N S R AT I O N A L E S

Provide only decaffeinated drinks during all 24 hours.

Spend [amount] minutes with the client in activity of theclient’s choice at least twice a day.

Provide appropriate positive reinforcement for achieve-ment of steps toward reaching a normal sleep pattern.

Talk the client through deep muscle relaxation exercisefor 30 minutes at 9 P.M.

Sit with the client for [amount] minutes three times a dayin a quiet environment, and provide positive reinforce-ment for the client’s accomplishments.

Caffeine stimulates the central nervous system.

Increases mental alertness and activity during daytimehours.

Positive reinforcement encourages behavior.

Facilitates relaxation and disengagement from the activi-ties and thoughts of the day to prepare the client bothphysically and mentally for sleep.

Positive reinforcement encourages calm behavior andenhances self-esteem.

● N O T E : This is for clients with increased activity.

Go to the client’s room and walk with him or her to thegroup three times a day.

Spend time out of the room with the client until he or shedemonstrates ability to tolerate 30 minutes of interac-tion with others.35

Stimulates wakefulness during daytime hours, and facili-tates the area development of a trusting relationship.

Stimulates wakefulness during daytime hours.

● N O T E : This is for clients with depressed mood.

Spend 30 minutes with the client discussing concerns2 hours before bedtime.

Facilitates problem-solving during daytime hours ata time when normal sleep patterns will not bedisturbed.

Gerontic HealthA C T I O N S / I N T E R V E N T I O N S R AT I O N A L E S

Collaborate with the physician and pharmacist, if asleeping medication is prescribed, to ensure that thedrug is one that minimally interferes with the normalsleep cycle.

Assess for the presence of physical causes of interruptedsleep and provide referrals as needed:

• Prostatic hypertrophy leading to nocturia.• Prescription medications that may interrupt normal

sleep patterns (beta-blockers are commonly used in eld-erly clients and can cause nightmares and insomnia).

• Recent losses or grief can lead to altered sleep patterns.• Some cardiac disorders can lead to orthopnea.

Monitor for the presence of pain prior to bedtime andif the patient is found awake frequently during thenight.

Monitor for symptoms of depression,36 especially if theolder adult reports waking very early in the morningwith an inability to fall back to sleep, and is experienc-ing feelings of anxiety on awakening.

This ensures that the older adult has as natural a sleeppattern as possible.

Untreated pain may prevent the onset of sleep and inter-rupt the individual’s usual sleep pattern.

Depression is frequently underreported and undertreatedin older adults.




••••••


Home Health


Involve the client and family in planning, implementing,and promoting restful environment and sleep routine:

• Coordinate family activities and the client’s sleep needsto maximize both schedules.

• Request that visits and calls be at specified times sothat sleep time is not interrupted.

• Provide favorite music, pillows, bedclothes, teddybears, etc.

• Support usual bedtime routine as much as possible inrelation to medical diagnosis and the client’s condition.

• Assist the client with maintaining a consistent bedtimeroutine as necessary.

Provide client/family teaching about medications thatmay disrupt normal sleep patterns:

• Hypnotics• Diuretics• Antidepressants and stimulants• Alcohol• Caffeine• Beta-adrenergic blockers• Benzodiazepines• Narcotics• Anticonvulsants


• Good ventilation• Quality mattress• Quiet sleep environment or soft “white” noise, if

preferred• Dark sleep environment with soft night lights, if preferred• Where possible the bedroom should be used for sleep-

ing only. Work, television viewing, studying, and otheractivities should be done in other rooms.

• Unplug telephone in room, or adjust volume controlon bell.



alterations in the normal sleep cycle.Assist the client/family in developing an eating/diet plan

to facilitate effective sleep patterns:• Avoid large, heavy meals at night.• Avoid caffeine in the evening.• Identify food allergies and avoid allergens.• Maintain a normal, healthy body weight.

Household involvement is important to ensure the envi-ronment is conducive for sleep and rest.


Readiness For Enhanced Sleep 437

••••••

Maintain pain control via appropriate medications, bodypositioning, and relaxation. Narcotics can suppressREM sleep and lead to increased daytime sleepiness.

Encourage self-care, exercise, and activity as appropriateand based on medical diagnosis and client condition.

Pain disturbs or prevents sleep and rest.

Sleep–rest patterns are stabilized by a balance of activityand exercise.

SLEEP, READINESS FOR ENHANCED

DEFINITION19

A pattern of natural, periodic suspension of consciousnessthat provides adequate rest, sustains a desired lifestyle, andcan be strengthened.


1. Expresses willingness to enhance sleep.2. Amount of sleep and REM sleep is congruent with

developmental needs.3. Expresses a feeling of being rested after sleep.4. Follows sleep routines that promote sleep habits.5. Occasional or infrequent use of medications to induce

sleep.


1. Long work hours or shift in work hours2. Environmental impacts of modern living3. Jet lag4. Driving while fatigued5. Life changes that affect one’s sleep patterns and/or

characteristics


FatigueThe patient will complain of lack of energy andbeing tired during the day, as well as having diffi-

culty in maintaining his or her usual activities.However, assessment documents that thisfatigue exists regardless of the amountof sleep.

Health-Seeking BehaviorsThe patient will tell the health-care provider thatthey need assistance with sleep, whether with medi-cation or a change in environment, when in actualitythe patient documents adequate sleep for age andlife cycle.

Ineffective CopingPatient complains of inability to cope related to lackof sleep, when in reality, there is another factor ofworry, fear, or lifestyle which is interfering withpatient’s sleep patterns.

EXPECTED OUTCOME

The client will sleep at least (number) hours in 24 hours by(date).

The client will demonstrate effective sleep habits by(date).

TARGET DATES

Since this is a positive diagnosis, target dates should be 1 to2 days after diagnosis.



Adult Health


Collaborate with patient to develop sleep scheduleAssist patient in developing environment that promotes

restful sleep. Note that plan here.Have patient identify actions that enhance and deter rest-

ful sleep.Devise schedule to gradually taper reliance on sleep med-

ications.

Have patient keep journal about sleep pattern. Reviewweekly.

Allows identification of progress of plan of care andalterations as necessary




••••••

Women’s Health

Women’s Health will follow the same interventions and rationales as does Adult Health, Home Health, and GeronticHealth, except for the following:


Assess sleeping arrangements of childbearing couples,particularly after the birth of the new baby.

Be sensitive to cultural diversity and family sleepinghabits.

Assess lifestyle changes that the addition of a new babybrings to the household

Assist women who are approaching midlife and experi-encing perimenopause and menopause plan and learnmethods of continuing to maintain healthy sleep pat-terns. Some tips to share are:

• Avoid shift work if possible, especially switching shiftsat work on a routine basis.

• Avoid caffeine, alcohol, and nicotine.• Exercise, but not too close to bedtime.• Avoid naps.• About an hour before going to bed:

• Engage in a relaxing, nonalerting activity.• Do not drink or eat too much.

• Maintain a quiet, dark, and preferably cool, but com-fortable sleep environment.

A through assessment of sleeping arrangements, culturalinfluences, sleeping habits of the parents, presence ofpets in the household, and any additional lifestylechanges that have occurred since the arrival of the newbaby will allow the health care provider to make sug-gestions and help the couple plan. This planning willhelp the couple to maintain their sleep patterns andpromote enhanced readiness for sleep.7,8,25

Women who are aware of their life-cycles and know whatto expect can better plan and implement changes intheir environment that will help them maintain goodsleeping habits. That will prevent sleep problems andpromote optimal sleep and show enhanced readinessfor sleep.1,11,12,14–16


Child Health


Assess for all contributory factors, especially evidence forpattern of sleep, which are appropriate for develop-mental age and status.

Foster current daily regimen with specific attention tocontinuing plan for sleep routine.

Provide opportunity for development of mutually agree-able ongoing guidelines for caregiver(s) and/or child,as appropriate, to continue to monitor sleep patternswith best practice to attain desired sleep.37

Offer instructions according to caregiver(s) baselineknowledge of sleep, especially regarding aids to sleep,need for maintenance of schedule, and routine for sleep.

Offer resources according to infant or child’s age/devel-opmental status.

Warn caregiver(s) of dangers of co-sleeping and of riskfor SIDS for young infants.37

Provides realistic base for plan.

Values current need for sleep and success in attainmentof desired plan for adequate rest.

Provides anticipatory guidance for plan.

Provides a realistic basis for teaching and likelihood offollow-up for plan.

Provides appropriate anticipatory guidance for realisticexpectations.

Offers safe anticipatory guidance.7,37

Childcare programs outlines what should be included inthe safe sleep policy (http://www.healthychildcare.org/pdf/SIDSchildcaresafesleep.pdf)


Readiness For Enhanced Sleep 439

••••••



Provide the client/family teaching about medications thatmay disrupt normal sleep patterns:

• Hynotics• Diuretics• Antidepressants and stimulants• Alcohol• Caffeine• Beta-adrenergic blockers• Benzodiazepines• Narcotics• Anticonvulsants


• Good ventilation• Quality mattress• Quiet sleep environment or soft “white” noise, if pre-

ferred• Dark sleep environment with soft night lights, if pre-

ferred• Where possible the bedroom should be used for sleep-

ing only. Work, television viewing, studying, and otheractivities should be done in other rooms.

To prevent sleep problems.


Mental HealthSpend [number] minutes [number] times a day discussing

with client his or her perceptions of current sleep pat-terns. [Note the schedule of these meetings here.]

Develop, with the client, a plan for addressing his or herneeds for sleep enhancement.

• Utilize information about sleep hygiene to guide clientin plan development (See information on sleep hygienein Sleep Deprivation care plan).

[Note the client’s plan here with information about theassistance needed from nursing for goal achievement.]

Develop, with the client, a plan for rewarding positivebehavior change.

[Note the plan for rewarding behavior here.]

Change is dependent on the client’s perception of theproblem.37

Positive reinforcement encourages behavior change.29,37

• Keep a sleep diary to identify your sleep habits andpatterns.

• Layer blankets, so that you can take them off or putthem on if you are experiencing “hot flashes.”

• Keep the bedroom cool and use only for sleep (do notwatch television in bed).





••••••

R E F E R E N C E S1. McGovern, J: The Basics of Sleep. Unpublished presentation,

Milwaukee, WI, 2005.2. Lavie, P, Malhotra, A, Pillar, G, and Dunitz, M: Sleep Disorders:

Diagnosis, Management and Treatment: A Handbook for Clinicians.Martin Dunitz, London, 2002.

3. Hayter, J: The rhythm of sleep. Am J Nurs 80: 457, 1980.4. Courtenay, WH: Behavioral factors associated with disease,

injury, and death among men: Evidence and implications for pre-vention. Int J Men Health 1:281, 2002.

5. Babisch, W: Noise and health. Environ Health Perspect 113:14, 2005.6. Lee, K: Rest status. In Mitchell, PH, and Loustau, A (eds): Concepts

Basic to Nursing, ed 3. McGraw-Hill, New York, 1981.7. Hockenberry, MJ. Wong’s Clinical Manual of Pediatric Nursing, ed 6.

CV Mosby, St. Louis, 2004.8. Lowdermilk, DL, and Shannon, EP: Maternity and Women’s Health

Care, ed 8. CV Mosby, St. Louis, 2004.9. Guilleminault, C: Sleep and Its Disorders in Children. Raven Press,

New York, 1987.10. Task Force on Sudden Infant Death Syndrome. Pediatrics 116: 1245,

2005.11. Vliet, EL: Screaming to Be Heard: Hormonal Connections Women

Suspect and Doctors Ignore. M. Evans and Co., New York, 1995.12. Kanusky, C: Health Concerns of Women in Midlife. In Breslin, ET,

and Lucas, VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice. Saunders, St. Louis, 2003.

13. Ancoli-Israel, S: Sleep problems in older adults: Putting myths to bed.Geriatrics 52:20, 1997.

14. Sellers, JB: Health care for older women. In Breslin, ET, and Lucas,VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.WB Saunders, St. Louis, 2003.

15. Bundlie, SR: Sleep in aging. Geriatrics 53:41, 1998.16. Beck-Little, R, and Weinrick, SP: Assessment and management of

sleep disorders in the elderly. J Gerontol Nurs 24:21, 1998.17. Miller, CA: Nursing Care of Older Adults: Theory and Practice, ed 3.

Lippincott, Philadelphia, 1999.18. McCurry, SM: Successful behavioral treatment for reported sleep

problems in elderly caregivers of dementia patients: A controlledstudy. J Gerontol 53:122, 1998.

19. Author: Nursing Diagnosis: Definitions and Classification,2005–2006, North American Nursing Diagnosis Association, NANDAInternational. 2005.

20. Stevenson, J, and Murphy, PM: Slumber, jack: 20 knockout tacticsguaranteed to help you sleep. Men’s Health 10:34, 1995.

21. Schmetzer, AD: The medicines for insomnia. Ann Am PsychotherAssoc 7(2):30, 2004.

22. Courtenay, WH: Behavioral factors associated with disease, injury,and death among men: Evidence and implications for prevention. JMen’s Studies 9(1):81, 2000.

23. What to swallow (or avoid) for better sleep. Tufts U Health Nutr Lett17: 1999.

24. Clinical practice guideline: Diagnosis and management of childhoodobstructive sleep apnea syndrome. April, NGC: 002431, AmericanAcademy of Pediatrics-Medical Specialty Society, 2002.

25. Yamazaki, A, Lee, KA, Kennedy, HP, and Weiss, SJ: Sleep-wakecycles, social rhythms, and sleeping arrangement during Japanesechildbearing family transition. JOGNN J Obstet Gynecol NeonatalNurs 34(3):342, 2005.

26. Yantis, M: Identifying depressing as a symptom of sleep apnea. JPsychosoc Nurs 37:28, 1999.

27. McFarland, G, Wasli, E, and Gerety, E: Nursing Diagnoses andProcess in Psychiatric Mental Health Nursing, ed 3. Lippincott,Philadelphia, 1997.

28. Townsend M: Psychiatric Mental Health Nursing: Concepts of Care,ed 3. FA Davis, Philadelphia, 2000.

29. Kneisl, C, Wilson, H, and Trigoboff, E: Contemportay Psychiatric-Mental Health Nursing, Pearson Education, Upper Saddle River,NJ, 2004.

30. McCloskey, J, and Bulechek, G: Nursing Interventins Classification,ed 2. Mosby-Year Book, St. Louis, 1996.

31. Floyd, JA: Sleep promotion in adults. Annu Rev Nurs Res 17:27, 1999.32. Driskell, JE, and Mullen, B: The efficacy of naps as a fatigue counter-

measure: A meta-analytic integration. Human Factors 47:1122, 2005.33. Fisch, R, et al: The Tactics of Change: Doing Therapy Briefly. Jossey-

Bass, San Francisco, 1982.34. Keane, SM, and Stella, S: Recognizing depression in the elderly. J

Gerontol Nurs 15:21, 1990.35. Author: Practice parameters for using polysomnography to evaluate

insomnia: An update: American Academy of Sleep Medicine—Professional Association. NGC: A 003292, 2003.

36. Author: Safe sleep for my grandbaby: Did you know that guidelinesfor safe sleep have changed since your children were babies? TheAmerican Academy of Pediatrics (http://www.sidsalliance.org), 2005.

37. Wright, L, and Leahey, M: Nurses and Families, ed 4. FA Davis,Philadelphia, 2005.






alterations in the normal sleep cycle.

Assist the client/family to develop an eating/diet plan tofacilitate effective sleep patterns:

• Avoid large, heavy meals at night.• Avoid caffeine in the evening.• Identify food allergies and avoid allergens.• Maintain a normal, healthy body weight.




7COGNITIVE–PERCEPTUAL PATTERN

1. ADAPTIVE CAPACITY, INTRACRANIAL, DECREASED 450

2. CONFUSION, ACUTE AND CHRONIC 454

3. DECISIONAL CONFLICT (SPECIFY) 463

4. ENVIRONMENTAL INTERPRETATION SYNDROME,IMPAIRED 469

5. KNOWLEDGE, DEFICIENT (SPECIFY) 474

6. KNOWLEDGE, READINESS FOR ENHANCED 479

7. MEMORY, IMPAIRED 482

8. PAIN, ACUTE AND CHRONIC 486

9. SENSORY PERCEPTION, DISTURBED (SPECIFY:VISUAL, AUDITORY, KINESTHETIC, GUSTATORY,TACTILE, OLFACTORY) 497

10. THOUGHT PROCESS, DISTURBED 506

11. UNILATERAL NEGLECT 514


PATTERN DESCRIPTION

Rationality, the ability to think, has often been describedas the defining attribute of humans. Thus, the cognitive–perceptual pattern becomes the essential premise for allother patterns used in the practice of nursing. Because itdeals with the adequacy of the sensory modes and adapta-tions necessary to negate inadequacies in the cognitive func-tional abilities, any failure in recognizing alterations in thispattern will hamper assessment and intervention in all theother patterns. The nurse must be aware of the cognitive–perceptual pattern as an integral and important part of holis-tic nursing.

The cognitive–perceptual pattern deals with thought,thought processes, and knowledge as well as the way thepatient acquires and applies knowledge. A major componentof the process is perceiving. Perceiving incorporates theinterpretation of sensory stimuli. Understanding how apatient thinks, perceives, and incorporates these processes tobest adapt and function is paramount in assisting him or herto return to or maintain the best health state possible.Alterations in the process of cognition and perception are aninitial step in any assessment.

In addition, the nurse–patient relationship identifieshuman response as a major premise for the nursing process.Ultimately, then, it is this very notion of thought and learn-ing potential that facilitates the self-actualization of humans.

PATTERN ASSESSMENT

1. Does intracranial pressure fluctuate after a singleactivity?a. Yes (Decreased Intracranial Adaptive Capacity)b. No

2. Does the patient have a problem with appropriateresponses to stimuli?a. Yes (Confusion)b. No

3. Does the patient have a problem with fluctuating levelsof consciousness (in the presence of inappropriateresponses to stimuli)?a. Yes (Acute Confusion)b. No (Chronic Confusion)

4. Does the patient indicate difficulty in making choicesbetween options for care?a. Yes (Decisional Conflict [Specify])b. No (Readiness for Enhanced Knowledge)

5. Is the patient delaying decision making regarding careoptions?a. Yes (Decisional Conflict [Specify])b. No (Readiness for Enhanced Knowledge)

6. Has the patient been disoriented to person, place, andtime for more than 3 months?a. Yes (Impaired Environmental Interpretation

Syndrome)b. No

7. Can the patient respond to simple directions orinstructions?a. Yes (Readiness for Enhanced Knowledge)b. No (Impaired Environmental Interpretation

Syndrome)8. Does the patient indicate lack of information regarding

his or her problem?a. Yes (Deficient Knowledge [Specify])b. No (Readiness for Enhanced Knowledge)

9. Can the patient restate the regimen he or she needs tofollow for improved health?a. Yesb. No (Deficient Knowledge [Specify])

10. Can the patient remember events occurring within thepast 4 hours?a. Yesb. No (Impaired Memory)

11. Review the mental status examination. Is the patientfully alert?a. Yesb. No (Disturbed Thought Process or Disturbed

Sensory Perception)12. Does the patient or his or her family indicate that the

patient has any memory problems?a. Yes (Disturbed Thought Process)b. No

13. Review sensory examination. Does the patient displayany sensory problems?a. Yes (Disturbed Sensory Perception [Specify])b. No

14. Does the patient use both sides of his or her body?a. Yesb. No (Unilateral Neglect)

15. Does the patient look at, and seem aware of, theaffected body side?a. Yesb. No (Unilateral Neglect)

16. Does the patient verbalize that he or she is experienc-ing pain?a. Yes (Acute Pain; Chronic Pain)b. No

17. Has the pain been experienced for more than6 months?a. Yes (Chronic Pain)b. No (Acute Pain)

18. Does the patient display any distraction behavior(moaning, crying, pacing, or restlessness)?a. Yes (Pain)b. No


A person who is able to carry out the activities of a normalcognitive-perceptual pattern experiences conscious thought,is oriented to reality, solves problems, is able to perceive viasensory input, and responds appropriately in carrying out the

442 Cognitive–Perceptual Pattern

••••••


usual activities of daily living in the fullest level of func-tioning. All these functions rely on a healthy nervous systemcontaining receptors to detect input accurately, a brain thatcan interpret the information correctly, and transmitters thatcan transport decoded information. Bodily response is alsoa basic requisite to respond to the sensory and perceptualdemands of the individual.

Cognition is the process of obtaining and using knowl-edge about one’s world through the use of perceptual abili-ties, symbols, and reasoning. For this reason, it includes theuse of human sensory capabilities to receive input about theenvironment. Cognition usually leads to perception, which isthe process of extracting information in such a way that theindividual transforms sensory input into meaning. Cognitionincorporates knowledge and the process used in its acquisi-tion; therefore, ideas (concepts of mind symbols) and lan-guage (verbal symbols) are two tools of cognition. Learningmay be considered the dynamic process in which perceptualprocessing of sensory input leads to concept formationand change in behavior. Cognitive development is highlydependent on adequate, predictable sensory input.

There are two general approaches to contemporarycognitive theory. The information-processing approachattempts to understand human thought and reasoningprocesses by comparing the mind with a sophisticated com-puter system that is designed to acquire, process, store, anduse information according to various programs or designs.

The second approach is based on the work of the Swisspsychologist Jean Piaget, who considered cognitive adapta-tion in terms of two basic processes: assimilation and accom-modation. Assimilation is the process by which the personintegrates new perceptual data or stimulus events into exist-ing schemata or existing patterns of behavior. In other words,in assimilation, a person interprets reality in terms of his orher own model of the world based on previous experience.Accommodation is the process of changing the model theindividual has of the world by developing the mechanisms toadjust to reality. Piaget believed that representational thoughtoriginates not in a social language but in unique symbols thatprovide a foundation later for language acquisition.1

American psychologist Jerome Bruner broadenedPiaget’s concept by suggesting that the cognitive process isaffected by three modes. The enactive mode involves repre-sentation through action, the iconic mode uses visual andmental images, and the symbolic mode uses language.1

Cognitive dissonance is the mental conflict that takesplace when beliefs or assumptions are challenged or contra-dicted by new information. The unease or tension the indi-vidual may experience as a result of cognitive dissonanceusually results in the person’s resorting to defense mecha-nisms in an attempt to maintain stability in his or her con-ception of the world and self.

In a broad sense, thinking activities may be consideredinternally adaptive responses to intrinsic and extrinsic stim-uli. The thought processes serve to express inner impulses,but they also serve to generate appropriate goal-seeking

behavior by the individual. Perceptual processes enhancethis behavior as well.

Perception is the process of extracting information insuch a way that the individual transforms sensory input intomeaning. The senses, which serve as the origin of perceptualstimuli, are as follows:

1. Exteroceptors (distance sensors)a. Visualb. Auditory

2. Proprioceptors (near sensors)a. Cutaneous (skin senses that detect and communicate,

or transducer, changes in touch, e.g., pressure, tem-perature, and pain)

b. Chemical sense of tastec. Chemical sense of smell

3. Interoceptors (deep sensors)a. Kinesthetic sense that senses changes in position of

the body and motions of the muscles, tendons, andjoints

b. Static or vestibular sense that senses changes relatedto maintaining position in space and the regulation oforganic functions such as metabolism, fluid balance,and sensual stimulation

It is important to note that because perceptual skillprocessing is an internal event, its presence and develop-ment are inferred by changes in overt behavior. For fullappreciation of the cognitive–perceptual pattern, it is alsonecessary to understand the normal physiology of the nerv-ous system.


INFANT

The full-term newborn has several sensory capacities. Theneonate should have a pupillary reflex in response to lightand a corneal reflex in response to touch. At birth, the sen-sory myelination is best developed for hearing, taste, andsmell.

Vision. Structurally, the eye is not completely differentiatedfrom the macula. The newborn has the capacity to fixatemomentarily on a bright or moving object held within8 inches and in the midline of the visual field. By approxi-mately 4 months of age, the infant is capable of 20/200visual acuity. Binocular fixation and convergence to nearobjects is possible by approximately 4 months of age. In asupine position, the infant can follow a dangling toy fromthe side to past midline.

Hearing. The neonate is capable of detecting a loud soundof approximately 90 decibels and reacts with a startle. Atbirth, all the structural components of the ear are fully devel-oped. However, the lack of cortical integration and fullmyelination of the neural pathways prevents specificresponse to sound. The infant will usually search to locate


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sounds. By approximately 15 months of age, the infant isbeginning to acquire eye–hand coordination and is capableof accommodation to near objects. Of concern at this agewould be any abnormalities noted in any of these tasks plusrubbing of eyes, self-rocking, or other self-stimulatingbehavior. By approximately 2 months, the infant will turn tothe appropriate side when a sound is made at ear level. Byapproximately 20 months, the infant will localize soundsmade below the ear. A cause for concern might be failure tobe awakened by loud noises or abnormal findings in any ofthe previously mentioned responses. Speech or the utteringof sounds by age 6 to 8 months would also be a component.

Smell. Smell seems to be a factor in breastfed infants’response to the mother’s engorgement and leaking.Newborns will turn away from strong odors such as vinegarand alcohol. By approximately 6 to 9 months, the infantassociates smell with different foods and familiar people ofhis or her circle of activity. The infant also avoids strong,unpleasant odors.

Taste. The newborn responds to various solutions with thefollowing facial reflexes:

1. A tasteless solution elicits no facial expression.2. A sweet solution elicits an eager suck and look of satis-

faction.3. A bitter liquid produces an angry, upset expression.

By 1 year of age, the infant shows marked prefer-ences, with similar responses to different flavors, as did theyoung neonate.

Touch. At birth, the neonate is capable of perception oftouch, and the mouth, hands, and soles of the feet are themost sensitive. There is increasing support for the notionthat touch and motion are essential to normal growth anddevelopment.

By 1 year of age, the infant has a preference for softtextures over rough, grainy textures. The infant relies on thesense of touch for comforting. Over-response or under-response to stimuli, for example pain, is a cause for concern.

Proprioception. At birth, the infant is limited in perceiv-ing itself in space, because this requires deep myelinationand total integration of cortical activity. There is momentaryhead control. In general, referral to more exacting neurologicreflexes of the neonate will provide in-depth supplementarydata. In essence, primitive reflexes, which are protective innature, serve to assist the neonate in adjustment to extrauter-ine life and identification of congenital anomalies. A criticalappreciation of organic and operational synergy for the cen-tral nervous system is necessary as sensory deficits are con-sidered.

By approximately 3 months of age, the infant will,when suspended in a horizontal prone position with the headflexed against the trunk, reflexively draw up the legs. This isknown as the Landau reflex. It remains present until approx-imately 12 to 24 months of age. Another related reflex is theparachute reflex, in which the infant, on being suspended in

a horizontal prone position and suddenly thrust downward,will place hands and fingers forward as an attempt to protecthim- or herself from falling. This reflex appears at approxi-mately 7 months and persists indefinitely.

The neonate responds with total body reaction to apainful stimulus. The primitive reflexes demonstrate this,especially the Moro, or startle, response to sudden loss ofsupport or loud noises. The neonate is dependent on othersfor protection from pain. The mother of a newborn is mostoften the person who assumes this task, along with the fatherand other primary caregivers. For this reason, managementof pain must also include the parents. Distraction, for exam-ple, a pacifier, is useful in dealing with painful stimuli.

The infant gradually offers localized reaction inresponse to pain at approximately 6 to 9 months of age. Still,the cognitive abilities of the infant remain limited withrespect to pain. Often a physical tugging of the painful bodypart proves to be the clue of pain for the infant, as with anearache. The infant is incapable of offering cooperation inprocedures and must be physically restrained, because he orshe is largely incapable of resisting painful stimuli. Cryingand irritability may also be manifestations of pain, particu-larly when the nurse is certain other basic needs have beenattended to.

If chronic pain comes to be a way of life for the infantsoon after birth or before much development has occurred,there may be alterations in any subsequent development. Insome instances, infants adapt and develop high tolerancesfor pain.

The neonate is dependent on others for appropriatecare and health maintenance. Values for health care arebeing formed through this provision of care by others. Theinfant will gradually continue to learn values of health care.Safety becomes an ongoing concern, as has been previouslyacknowledged. Parents or primary caregivers assume thisresponsibility. The infant is capable of object permanencebut cannot be expected to remember abstract notions.

The neonate subjected to hypoxia in the perinatalperiod is at risk for possible future developmental delays.Apgar scores are typically used as criteria, in addition toneurologic reflexes. Seizures during the neonatal periodmust also be followed up. In a general sense, the prematureinfant of less than 37 weeks’ gestation should also be con-sidered at risk for developmental delays. It is paramount thatclose examination be performed for basic primitive reflexesand general neonatal status as well as identification of anygenetic syndromes or congenital anomalies.

The infant gradually incorporates symbols and inter-acts with the world through primary caregivers. Any majordelays in development should be cause for further closefollow-up. Sensory-perceptual deficiencies may indeedbring about impaired thought processes.


Binocular vision is well established by now. The toddler candistinguish geometric shapes and can demonstrate begin-


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ning depth perception. Marked strabismus should be treatedat this time to prevent amblyopia. The toddler can begin toname colors.

Smell, taste, and touch all become more related as thetoddler initially sees an object and handles it while enjoying,via all the senses, what it is to “know.” Regression to previ-ous tactile behavior for comfort is common in this group, asexemplified by a preference for being patted and rocked tosleep during times of stress, such as illness. Concerns by thistime would be for secondary deficits in development thatmay arise. There is also a great concern for the toddler whoshows greater response to movement than to sound or whoavoids social interaction with other children. By this time,speech should be sufficiently developed to validate a basicsense of the toddler’s ability to use symbols. Proprioceptionis not perfected, but “toddling” represents a major milestone.Falls are common at this age.

There is an even greater incorporation of sensoryactivity in sequencing for the preschooler, in whom majormyelination for the most part is fully developed. There isrefinement of eye–hand coordination, and reading readinessis apparent. Visual acuity begins to approach 20/20, and thepreschooler will know colors. Before age 5, the child shouldbe screened for amblyopia; after age 5, there is minimalpotential for development of amblyopia. Language becomesmore sophisticated and serves to provide social interaction.By this age, the child will remember and exercise cautionregarding potential dangers, such as hot objects.

The toddler may regress to previous behavior levelswith physical resistance in response to painful stimuli. Thiswill be especially true with invasive procedures. On occa-sion, a toddler may demonstrate tolerance for painful proce-dures on the basis of understanding benefits offered, forexample, young children with a medical diagnosis ofleukemia. This is not the usual case, however. Tempertantrums, outbursts, and avoidance of painful stimulidescribe the usual behavior of the toddler. When the toddlermust deal with chronic pain, he or she may regress to previ-ous behavior as a means of coping.

The preschooler views any invasive procedure asmutilation and attempts to withdraw in response to pain.The preschooler cries out in pain and will express feel-ings in his or her own terms as descriptors of pain. The inter-pretation of pain is influenced greatly by the parental andfamilial value systems. In severe pain, the potential forregression to previous behavior is high. The nurse should beaware that fears of abandonment, death, or the unknownwould be brought out by pain for this age group. Also, theeffect the pain has on others may serve to further frightenthe child.

Play is an ideal noninvasive means of assessment.Difficulties in gait, balance, or the use of upper limbs insymmetry with lower limbs should be noted, as well asrelated holistic developmental components includingspeech, motor, cognitive, perceptual, and social compo-nents. Allowance should be made for regression to priorpatterns as needed in times of stress, such as illness and hos-

pitalization. If a deficit exists, parents should be encouragedto continue appropriate follow-up and intervention.

The preschooler may be aware of how he or she isdifferent from peers, although egocentrism continues. Ofimportance is the mastery of separation from parents forincreasing periods of time. The likelihood of sibling inte-gration should be considered also. At this time, a knownneglect of one side of the body may be problematic, as thechild may rebel and fail to comply with desired therapy.

The toddler gradually learns to care for him- or herselfand is strongly influenced by the family’s value system.There is capacity for expression of beginning thoughts.

The preschooler has a capacity for magical thinkingand enjoys role-play of the parent of the same sex. At thisage, beginning resistance to parental authority is common,and the child is still egocentric in thought. This makes it dif-ficult to apply universal understanding of use of languageand symbols for children of this age; for example, death maybe perceived as “sleep.”

By this age, there should be a general notion of thecognitive capacity of the child. The child explores the worldin a meaningful fashion and still relies closely on primarycaregivers. If there are marked delays, they should be mon-itored with a focus on maintaining optimum functioningwith developmental sequencing.

The preschooler will enjoy activity and is beginning toenjoy learning colors, using words in sentences, and gradu-ally forming relationships with persons outside the immedi-ate family. If there are delays, they should continue to bemonitored. By now, major deficits in cognition becomemore obvious.

SCHOOL-AGE CHILD

The school-age child has a significant ability to perform log-ical operations. More complete myelination and maturationenhance the basic physiologic functioning of the centralnervous system. Generally, the school-age child can estab-lish and follow simple rules. There is self-motivation with agradual grasp of time in a more abstract nature. The conceptof death is recognized as permanent.

The school-age child begins to interpret the experi-ence of pain with a cognitive component—the cause orsource of pain, as well as implications for possible recur-rence. The child in this developmental category will attemptto hold still as needed, with an appearance of bravery.Expression of the experience of pain is to be expectedby a school-age child. If the school-age child is particularlyshy, special attempts should be made to establish a trustingrelationship to best manage pain. A major fear is loss ofcontrol. The nurse must consider the need to completelyevaluate chronic pain. In some instances, it may signalother altered patterns, especially a distressed family orinability to cope. Lower performance in school can bean indicator of chronic pain. Also, the nurse should beaware of the increased complexity required for activities ofdaily living (ADLs). The child of this age may feel negative


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about him- or herself if he or she is unable to perform aspeers do. The importance of group activities cannot be over-stressed.

The school-age child will blossom with a sense ofaccomplishment. When school does not bring success, frus-tration follows. It is mandatory that caution be exercised inassessing for deficits versus behavioral manifestations of notliking school.

ADOLESCENT

Vision. Acuity of 20/20 is reached by now. Squintingshould be investigated, as should any symptoms of pro-longed eyestrain.

Hearing. Further investigation should be done on any ado-lescent who speaks loudly or who fails to respond to loudnoises.

Touch. Over- or under-reaction to painful stimuli is a causefor further investigation.

Taste. The adolescent may prefer food fads for a length oftime, but concern is appropriate if the adolescent overusesspices, especially salt or sugar, or complains of foods not“tasting as they used to.”

Smell. The adolescent should distinguish a full range ofodors. The nurse should be concerned if the adolescent isunresponsive to noxious stimuli.

Proprioception. There may be temporary clumsinessassociated with growth spurts. The nurse should be con-cerned if he or she observes patterns of deteriorating grossand fine motor coordination and ataxia.

By now the adolescent is capable of formal opera-tional thought and is able to move beyond the world of con-crete reality to abstract possibilities and ideas. Problemsolving is evident with inductive and deductive capacity.There is an interest in values, with a tendency toward ideal-ism. Attention must be given to the adolescent’s sensitivityto others and potential for rejection if body image is altered.Of particular importance at this time are sports and peer-related activities. As feelings are explored more cautiously,there is a tendency to draw into oneself at this stage. Theremay be major conflicts over independence when self-care isnot possible.

The adolescent fears mutilation and attempts to dealwith pain as an adult might. Self-control is strived for, withallowance for capitalization on gains from pain. Sexualityfactors of role performance enter into this group as painoccurs. As with the adult, an attempt to discover the causeand implication of the pain is made. The adolescent experi-encing chronic pain will be at risk for abnormal peer inter-action and may potentially endure altered self-perception.

The adolescent will most often remain steady in cog-nitive functioning if there are no major emotional or sensoryproblems. Of concern at this age would be substance abusethat could impair thought processes.

ADULT AND OLDER ADULT

Vision. The adult is capable of 20/20 vision with a gradualdecline in acuity and accommodation after approximately40 years of age. There is a tendency toward farsightedness.Color discrimination decreases in later ages, with green andblue being the major hues affected. Depending on the cause,there is a great potential for the use of corrective aids. Inexamples of degenerative processes, such is not the case, aswith macular degeneration. Eventually depth perception andperipheral vision are also affected. There may also be sensi-tivity to light, as with cataract formation. The nurse shouldbe alert for all etiologic components, especially the retinopa-thy associated with diabetic alterations.

Hearing. The adult has sensitivity to accurately discrimi-nate 1600 different frequencies. There should be equal sen-sation of sounds for the left and right ear. The Rinne testmay be done to validate air and bone conduction via a tun-ing fork. The Weber test may be used to assess lateralization.Equilibrium assessment provides data regarding the vestibu-lar branch.

With time, the acuity of what is heard graduallydiminishes, with detection of high-pitched frequencies espe-cially affected. The nurse should be concerned with a lack ofresponse to loud noises and increased volume of speech, andshould be alert to cues of decreased hearing, such as cuppingof the hand on the “better” ear or leaning sideways to catchthe conversation on the “better” side.

Smell. There may be a gradual deterioration in sensitivityfor smell after approximately age 60, although for the mostpart the sense of smell remains functional in the absence oforganic disease. There may be altered gastrointestinalenzyme production, which ultimately interferes with usualperception of smells.

Taste. The ability to taste is well differentiated in adult-hood. Sweet and sour can be detected bilaterally. Concernmay be raised if the client states the sense of taste has dimin-ished or changed. There is a gradual loss of acuity in taste asaging occurs in later life. This is due in part to decreasedenzymatic production and utilization in digestive processes.Over-salting or -spicing of foods may serve as a clue to thisloss of taste sensation. The use of dentures may also affectthe sensation of taste and enjoyment of food.

Touch. The adult is able to discriminate on a wide range oftactile stimuli, including pressure, temperature, texture, andpain or noxious components. With aging, there is a decreasein subcutaneous fat, loss of skin turgor, increase in capillaryfragility, and a decrease in conduction of impulses. All thesechanges influence the sense of touch, with a loss of acuity inaging.

Proprioception. The adult is well coordinated and has akeen sense of perception of his or her body in space. Thereare multiple protective mechanisms that aid in maintainingbalance. Typically, even with eyes closed, the individual isable to stand and maintain balance.


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By now the tolerance and threshold one has for pain iswell established. The individual has learned various ways tocope with pain, and thus may be equipped with a more sta-ble base from which to respond. Paradoxically, the adult mayexperience unresolved conflicts of previous developmentlevels as well. For this reason, the required change may besubject to associated changes as pain and its response affectthe multiple demands of daily living by the adult.

The adult is equipped to solve problems and applyprinciples to everyday living. There is emphasis on seekinga lifetime mate who is able to satisfy basic companionshipneeds. There may be difficulties in accepting life’s chal-lenges as parents or as adults juggling the many necessaryroles. There is, in later life, a gradual decline in problem-solving capacity, which may be exaggerated by illness.

Allowing for potential decrease in bodily perceptionand functioning with age must be considered. As assessment

is carried out, focus should be on risk factors such as chronicillness, financial deficits, resolution of ego integrity versusdespair, and obvious etiologic components. The nurse shouldassist the patient to maintain self-care, as the patient desires.

With aging, there is a gradual loss of balance, perhapsmost related to the concurrent vascular changes. For this rea-son proprioceptive data may provide an immediate basis forsafety needs of the geriatric client.

In the absence of adversity, the adult enjoys the dailychallenges of living. If coping is altered for whatever reason,a risk for impaired thought process exists. With aging thereare potential risks for impaired thought processes. In addi-tion, there may be potential risks for some regarding degen-erative brain and central nervous system disorders, whichalso include impaired thought processes. Two concerns forolder adults related to altered thought processes are demen-tia and delirium or acute confusional states.


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GORDON’S FUNCTIONALHEALTH PATTERN NANDA NURSING DIAGNOSIS NIC PRIORITY INTERVENTIONS NOC EVALUATIONS

Cognitive–PerceptualPattern

Adaptive Capacity,Intracranial, Decreased

Confusion, Acute andChronic

Decisional Conflict (Specify)

Environmental Interpretation

Cerebral Edema ManagementCerebral Perfusion PromotionIntracranial Pressure (ICP)

MonitoringNeurologic Monitoring

AcuteDelirium ManagementDelusion Management

ChronicDementia ManagementDementia Management:

BathingMood Management

Decision-Making Support

Dementia Management

Neurological StatusNeurological Status:

ConsciousnessSeizure ControlTissue Perfusion: Cerebral

AcuteCognitive OrientationDistorted Thought Self-

ControlInformation ProcessingNeurological Status:

Consciousness

ChronicCognitionCognitive OrientationDecision-MakingDistorted Thought Self-

ControlIdentityInformation ProcessingMemoryNeurological Status:

Consciousness

Decision-MakingInformation ProcessingParticipation in Health Care

DecisionsPersonal Autonomy

Cognitive Orientation




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T A B L E 7 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 447)


Syndrome, Impaired

Knowledge (Specify),Readiness forEnhanced

Knowledge, Deficient(Specify)

Memory, Impaired

Dementia Management:Bathing

*Still in Development

Parent Education: Adolescent,Childrearing Family, Infant,

Teaching: Disease Process,Foot Care, Individual, InfantNutrition, Infant Safety,Infant Stimulation, Peri-operative, PrescribedActivity/Exercise, PrescribedDiet, Prescribed Medication,Procedure/Treatment,Psychomotor Skill, SafeSex, Sexuality, ToddlerNutrition, Toddler Safety,Toilet Training

Memory TrainingDementia ManagementEnvironmental Management:

Safety

ConcentrationFall Prevention BehaviorMemoryNeurological Status: ConsciousnessSafe Home Environment

Knowledge: Body Mechanics;Breastfeeding; Cardiac DiseaseManagement; Child PhysicalSafety; Conception Prevention;Diabetes Management; Diet;Disease Process; EnergyConservation; Fall Prevention;Fertility Promotion; HealthBehavior; Health Promotion;Health Resources; Illness Care;Infant Care; Infection Control;Labor and Delivery; Medication;Ostomy Care; Parenting;Personal Safety; PostpartumMaternal Health; PreconceptionMaternal Health; Pregnancy;Prescribed Activity; SexualFunctioning; Substance UseControl; Treatment Procedure(s);Treatment Regimen

Knowledge: Body Mechanics,Breastfeeding, Cardiac DiseaseManagement, Child PhysicalSafety, Conception Prevention,Diabetes Management, Diet,Disease Process, EnergyConservation, Fertility Promotion,Health Behavior, HealthPromotion, Health Resources,Illness Care, Infant Care, InfectionControl, Labor & Delivery,Medication, Ostomy Care,Parenting, Personal Safety,Postpartum Maternal Health,Preconception Maternal Health,Pregnancy, Prescribed Activity,Sexual Functioning, SubstanceUse Control, TreatmentProcedure(s), Treatment Regimen

CognitionCognitive OrientationConcentrationMemoryNeurological StatusNeurological Status:

Consciousness



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Pain, Acute and Chronic

Chronic

Sensory Perception,Disturbed (Specify:Visual, Auditory,Kinesthetic, Gustatory,Tactile, Olfactory)

Thought Processes,Disturbed

AcuteAnalgesic AdministrationPain ManagementPatient-Controlled Analgesia

(PCA) AssistanceSedation ManagementChronicAnalgesic AdministrationPain ManagementPatient-Controlled Analgesia

(PCA) AssistanceEnvironmental Management:

Comfort

VisualCommunication Enhancement:

Visual DeficitEnvironmental ManagementAuditoryCommunication Enhancement:

Hearing Deficit

KinestheticBody Mechanics Promotion

GustatoryNausea ManagementNutrition Management

TactileLower Extremity MonitoringPeripheral Sensation

ManagementTeaching: Foot CareOlfactoryEnvironmental ManagementNutrition Management

Delusion ManagementDementia ManagementEnvironmental Management:

Safety

AcuteComfort LevelPain ControlPain LevelStress Level

ChronicComfort LevelDepression LevelPain: Adverse Psychological

ResponsePain ControlPain: Disruptive EffectsPain Level

VisualSensory Function: VisionVision Compensation Behavior

AuditoryCommunication: ReceptiveHearing Compensation BehaviorSensory Function: HearingKinestheticBalanceBody Positioning: Self-InitiatedCoordinated MovementSensory Function: Proprioception

GustatoryAppetiteNutritional Status: Food & Fluid

IntakeSensory Function: Taste & SmellTactileSensory Function: Cutaneous

OlfactoryAppetiteNutritional Status: Food & Fluid

IntakeSensory Function: Taste & Smell

CognitionCognitive OrientationConcentrationDecision-MakingDistorted Thought Self-ControlIdentityInformation ProcessingMemoryNeurological Status:

Consciousness




ADAPTIVE CAPACITY,INTRACRANIAL, DECREASED

DEFINITION2

Intracranial fluid dynamic mechanisms that normally com-pensate for increases in intracranial volumes are compro-mised, resulting in repeated disproportionate increases inintracranial pressure (ICP) in response to a variety of nox-ious and nonnoxious stimuli.


1. Repeated increases in ICP of greater than 10 mm Hg formore than 5 minutes following any of a variety of exter-nal stimuli

2. Baseline ICP equal to or greater than 10 mm Hg3. Disproportionate increase in ICP following single envi-

ronmental or nursing maneuver stimulus4. Elevated P2 ICP waveform5. Volume pressure response test variation (volume: pres-

sure ratio greater than 2, pressure–volume index lessthan 10)

6. Wide amplitude ICP waveform

RELATED FACTORS2

1. Decreased cerebral perfusion pressure less than or equalto 50 to 60 mm Hg

2. Sustained increase in ICP greater than or equal to 10 to15 mm Hg

3. Systemic hypotension with intracranial hypertension4. Brain injuries


1. Head injury2. Cerebral ischemia3. Cranial tumors4. Hydrocephalus5. Cranial hematomas

6. Arteriovenous formation7. Vasogenic or cytotoxic cerebral edema8. Hyperemia9. Obstruction of venous outflow


Ineffective ProtectionThis diagnosis is typically associated with immune dis-orders or clotting disorders. However, maladaptivestress response and general neurosensory alterationsare also associated with Ineffective Protection.Decreased Intracranial Adaptive Capacity is a specificdiagnosis related to intracranial fluid dynamic mecha-nisms.

Excess Fluid VolumeThis diagnosis refers to the overall fluid in the body.Body fluid may be normal in Decreased IntracranialAdaptive Capacity. However, the intracranial fluid vol-ume and pressure are abnormal.

Ineffective Tissue PerfusionThis diagnosis defines a decrease in nutrition andoxygenation at the cellular level due to a deficit incapillary blood supply and may be a companion diag-nosis to Decreased Intracranial Adaptive Capacity,depending on the cerebral perfusion pressure and thesecondary physiologic cellular damage brought on bythe brain injury.

EXPECTED OUTCOME

Will have ICP (Intracranial Adaptive Capacity) within nor-mal range by [date].

TARGET DATES

Decreased Intracranial Adaptive Capacity is a life-threaten-ing condition, and should have target dates in terms ofhours. After stabilization, the time frame may be moved to48-hour increments.


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Unilateral Neglect Unilateral NeglectManagement

Environmental Management:Safety

Adaptation to Physical DisabilityBody Positioning: Self-InitiatedCoordinated Movement


Adaptive Capacity, Intracranial, Decreased 451

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Adult Health


Perform neurologic assessments at least q1h, includingthe Glasgow Coma Scale, pupillary response, andstrength. Also trend VS, ICP, and cerebral perfusionpressure (CPP) at a similar frequency.

Implement measures that decrease susceptibility forelevated ICP:

• Minimize environmental stimuli (light, sounds, andvisitors).

• Elevate head of bed 0 to 30 degrees. Institute measuresto keep head and neck in a neutral position (e.g., use ofa towel roll).

• Avoid hip flexion of more than 90 degrees.• Give medications for pain and agitation as needed.• Maintain euthermia.

• Interpret arterial blood gases and collaborate withrespiratory therapy to ensure ventilator settings areappropriate.

• Initiate an appropriate bowel regimen.Collaborate with the health-care team regarding therapy

to guard against vasospasm including hypervolemic,hypertensive, and hemodilutional therapy.

Collaborate with the health-care team regarding pharma-cological therapy including antiseizure medications,calcium channel blockers, pain control, etc.

Analyze lab work including electrolytes, complete bloodcount, serum osmolality and coagulation studies.

Suction cautiously as needed.

Cluster nursing intervention and minimize stimulation.

Collaborate with the health-care team regarding targetfluid volume status:

• Manage external ventricular drainage systems or moni-toring devices according to the standard of care.

Allows for continuous monitoring of the patient’s condi-tion and allows for early detection of complicationsand capacity for the adaptive response.

Minimizes fluctuations in ICP and CPP.3

Promotes venous drainage from the head.4

Agitation can elevate ICP.Hyperthermia increases cellular metabolism and subse-

quently ICP. Hypothermia may elicit shivering, whichalso will increase O2 consumption and ICP.

Hypercapnia can increase ICP.

Straining or Valsalva can increase ICP.

Provides insight into fluid–volume balance, progress inplan of care, and need for alterations.

Integral to facilitating gas exchange. Caution must beused as suctioning can cause increase in ICP.5–7

Many activities including coughing, sneezing, vomiting,bathing, pain, dressing change, agitation, spontaneousmovement, can increase ICP6,8,9

Ensures therapeutic goals are achieved related to ade-quate cerebral perfusion, minimizing hypoperfusedareas, and minimizing vasospasm.

Child Health


Monitor for factors contributing to altered intracranialpressure including medical/physiologic deviation andrelated issues, especially positioning, treatments, med-ications, suctioning, ventilation, etc.

Carry out thorough neurologic assessment according tothe degree of stimulation and movement permitted perthe infant’s or child’s status.

Thorough evaluation for contributing factors allows forearly detection of complications.

Deviations from norms will assist in differential workupand expedite treatment plan.




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Child Health


Maintain the head of bed at greater than 30 degrees, withthe head in line with the body, and, ideally, not posi-tioned from side to side unless specified. (Avoid use ofpillows under the patient’s head.) Recheck every 1 to2 hours.

Offer a calm, supportive environment with attentionto safety of airway maintenance, side rails up withpadding, and availability of emergency equipmentaccording to the infant’s or child’s needs.

Develop a daily plan of care that best matches the devel-opmental capacity of the infant or child, yet allows forpossible regression. [Note plan here.]

Incorporate parental input in the daily plan of care asappropriate. [Note parent preferences here.]

Offer time (30 minutes each shift and as needed) forparents to ventilate feelings regarding the infant’s orchild’s status.

Assess caregiver(s) knowledge level for care of the infantor child.

Provide appropriate teaching regarding equipment, proce-dures, surgery, etc. [Note teaching plan here.]

Offer gentle massage, and monitor carefully skin integrityand tissue perfusion, especially when the conditionlasts more than 2 days.

Check for potential untoward effects of medications,and exercise caution in appropriate dilution for IVadministration.

Maintain ongoing communication with the family to offerupdates on the infant’s or child’s condition.

Encourage the parents to bring the infant’s or child’sfavorite blanket, small toy, or security object if possible.

Arrange for appropriate follow-up, including homehealth, physical therapy, or neurology, especially whenthere may be a ventricular peritoneal (V–P) shunt. Forexample, including when to notify primary careprovider for possible infection or malfunction.

Neutral body alignment will assist in stabilizing theintracranial adaptation.

Few stimuli will enhance the infant’s or child’s likelihoodof rest during acute phase, while anticipatory safe-guarding will minimize further injury.

Previous skills may not be able to be remastered, oraltered temporarily because of illness in the pediatricclient.

Family will feel valued, and their input will assist in pro-viding some familiarity to the infant or child and lesseneffects of multiple caregivers.

Assists in reducing anxiety, and offers cues regardingparental concerns.

Provides a realistic base for teaching needs.

Knowledge allows for acceptance.

Likelihood of skin breakdown increases when reposition-ing is limited.

Likelihood of interaction increases with three or moremedications, and inappropriate administration maylikewise cause side effects.

Trust in caregivers will be enhanced if the family can bekept abreast of activities on an ongoing basis.

Familiar favored objects offer a sense of security in anotherwise foreign setting, thereby reducing stress.

Appropriate referral will foster long-term continuedregimen and offer goals over time.10,11

Women’s Health

For Women’s Health, see Adult Health, except for the following interventions:


Hypertensive Disorders of Pregnancy Gestational hypertensive disorders, including pre-eclamp-sia and eclampsia, and chronic hypertension compli-cate pregnancy.13


Adaptive Capacity, Intracranial, Decreased 453

••••••


Place on continuous intensive monitoring (cardiac andfetal). Observe blood pressure, urine output, reflexes,headache, visual problems, irritability/changes inaffect, and epigastric pain.7,8

Progression from pre-eclampsia to severe pre-eclampsiato eclampsia can occur.

To prevent progression to eclampsia:• Place in a darkened, quiet environment, to decrease

external stimuli.• Constantly monitor signs and symptoms of progression

of disease.

Place padded tongue blade at head of bed.Suction equipment and oxygen should be available, and

emergency medication tray and emergency birth packshould be accessible.

Carefully monitor magnesium sulfate (MgSO4) levels, ifappropriate, for therapeutic dose and/or toxicity.

Monitor fetal heart tone (FHT).

Assist the patient in orientation to time and place.

Do not allow the patient to ambulate alone. Provide assis-tance. Provide a bedside commode.

HELLP Syndrome: laboratory diagnosis for variant ofsevere preeclampsia that involves hepatic dysfunction:Hemolysis (H)Elevated liver enzymes (EL)Low platelets (LP)

NewbornCarefully assess the newborn for cranial injury.

Carefully examine the infant’s skull. Note the anteriorand posterior fontanels. Be especially alert for abulging anterior fontanel indicative of:

• Increased intracranial pressure• Major hemorrhage• Hydrocephalus

The reason for difficulty in diagnosing hypertension hasbeen a lack of standardization in blood pressure meas-urement. It is important for the health care provider toestablish a baseline and monitor throughout the preg-nancy.12,13

Monitor maternal parameters:Pre-eclampsia—usually occurs after the 20th week of

pregnancy, gestational hypertension plus presence ofproteinuria.

Severe pre-eclampsia—systolic 160 mmHgDiastolic blood pressure 110 mmHg, plus proteinuria,

plus oliguria, cerebral or visual disturbances, hepaticinvolvement, thrombocytopenia and pulmonary orcardiac involvement.

Eclampsia—onset of seizure activity or coma with no his-tory of existing pathology.13

Reduction of external stimuli can reduce or prevent con-vulsions in these patients. They need the reduction oflight to lessen eye pain and headache.

Seizure precautions and medications close at hand to usequickly. As this disease can progress quickly, evenwhen every precaution is taken.13

Often lethargy and confusion are the result of MgSO4therapy for eclampsia.

These patients feel out of control, lethargic, and confusedand cannot remember what has just been said to themas a result of both the convulsion and the medication.They need specific direction and a lot of support andunderstanding.

Associated with increased risk for both mother and fetus,as well as adverse outcomes. Increased risk for pla-centa abruption, renal failure, preterm birth and fetalor maternal death.13,14




••••••


Mental Health

The nursing actions for Mental Health for this diagnosis are the same as the actions presented in the Adult Health section.

Home Health

See Adult Health care plan. If the patient with this diagnosis is living in the home, professional home care will be required.

Gerontic Health


Maintain the head in a neutral position, even while thepatient is side-lying.

Prevents increases in pressure from flexion or extensionof the head.

● N O T E : Nursing interventions found in the Adult Health section are appropriate tothis age group. Caution must be used because of the potential for problems regardinghydration, hypothermia, pupillary reaction, deficits related to eye surgery, and risk forsensory deprivation with decreased activity.

CONFUSION, ACUTE AND CHRONIC

DEFINITIONS2

Acute Confusion Abrupt onset of a cluster of global, tran-sient changes and disturbances in attention, cognition, psy-chomotor activity, level of consciousness, and/or sleep–wakecycle.

Chronic Confusion Irreversible, long-standing and/or progressive deterioration of intellect and personality char-acterized by decreased ability to interpret environmentalstimuli and decreased capacity for intellectual thoughtprocesses and manifested by disturbances of memory.


A. Acute Confusion1. Lack of motivation to initiate and/or follow through

with goal-directed or purposeful behavior2. Fluctuation in psychomotor activity3. Misperception4. Fluctuation in cognition5. Increased agitation or restlessness6. Fluctuation in level of consciousness7. Fluctuation in sleep–wake cycle8. Hallucination

B. Chronic Confusion1. Altered interpretation or response to stimuli2. Clinical evidence of organic impairment3. Progressive and/or long-standing cognitive

impairment4. Altered personality5. Impaired memory (short term and long term)

6. Impaired socialization7. No change in level of consciousness

RELATED FACTORS2

A. Acute Confusion1. Older than 60 years of age2. Alcohol abuse3. Delirium4. Dementia5. Drug abuse

B. Chronic Confusion1. Multi-infarct dementia2. Korsakoff’s psychosis3. Head injury4. Alzheimer’s disease5. Cerebral vascular accident


1. Head injury2. Cerebral vascular accident3. Alzheimer’s disease4. Chemical abuse5. Dementia


Disturbed Sensory PerceptionAn alteration in one of the senses could create ashort-term confusion that is correctable. If a sensorydeficit is found, the most correct diagnosis isDisturbed Sensory Perception.


Confusion, Acute and Chronic 455

••••••

Disturbed Thought ProcessThe individual has a problem with cognitive operationand engages in nonreality thinking. Other functioningis normal. Confusion causes problems in both mentaland physical functioning.

Impaired MemoryThis diagnosis is related to memory only. Other cogni-tive functioning may be normal.

EXPECTED OUTCOMES

1. If acute, will be oriented �3 (person, place, and time)by [date].

2. If chronic, family/support system will identify [number]measures to maintain the client’s optimal functioning by[date].

3. If chronic, will demonstrate no signs/symptoms [noteclient-specific signs of anxiety] in current living situa-tion by [date].

TARGET DATES

For acute confusion, an appropriate target date would be72 hours after admission. Chronic confusion may be perma-nent, but the family should be able to learn appropriate inter-vention techniques within 72 hours.


Adult Health


Identify self and the patient by name at the beginning ofeach interaction.

Speak slowly and in short, clear, concrete, simple sen-tences and words.

Periodically orient and/or reorient the patient to the envi-ronment.

When the patient is delusional, focus on underlying feel-ings and reinforce reality (have clocks, calendars, etc.,on the wall). Do not argue with the patient.

When hallucinations and/or illusions are present, rein-force reality and attempt to identify underlying feelingsor environmental stimuli.

If the patient becomes aggressive, focus on underlyingfeelings and attempt to refocus interaction on topicsmore acceptable and/or less threatening to the patient.

Keep the patient’s room well lighted. Maintain a calmenvironment.

Encourage the patient to wear and use personal devices(eyeglasses or hearing aids).

During abusive episodes, ignore insults and focus onunderlying feelings. Set limits on behavior if physi-cally abusive.

Memory loss necessitates frequent orientation to person,time, and environment.

Allows time for information processing, and avoids useof complex statements and abstract ideas.

Helps alleviate anxiety brought on by changing levels oforientation, and helps meet safety needs of the patient.

Recognizing and/or acknowledging feelings may decreasethe patient’s anxiety, and give him or her a sense ofbeing understood. Arguing may increase the patient’sanxiety and reinforce intensity delusions.15

False and/or distorted sensory experiences are common inconfused states. To help decrease anxiety, focus onfeelings underlying these experiences while calmlyreinforcing reality.15

Focusing on feelings increases the patient’s feelings ofbeing understood, and discussing nonthreatening topicsincreases the patient’s sense of competency and self-esteem.

Decreases possibility of environmental sensory mis-representations, and helps meet patient safety needs.Patients with confusion are experiencing increasedlevels of anxiety and can become physically andmentally exhausted. Promoting rest often means con-trolling environmental stimuli that contribute to theconfusion.

These items increase accuracy of visual and auditory per-ceptions.

Projection of fear and anger onto persons in the environ-ment is common in confused states. Arguing with orbecoming defensive escalates the situation and adds tothe patient’s fear and anger.




••••••

Child Health11,16

Although intended for the population older than 60 years of age, confusion may occur in younger people as well, as aresult of similar causes. Uncertainty may be greater regarding potential for recovery because of age, exact cause of prob-lem, and so on.


AcuteMonitor for potential contributory factors, especially as

applicable:• Prenatal influences, i.e., drugs, sepsis• Previous health status• Known conditions, whether or not requiring treatment• Triggering event, trauma, surgery, emotional event• Daily routine or alterations

Determine with the parents previous patterns of develop-ment, and develop daily plan of care within capacityoffered by the infant’s or child’s status.

Identify current plan of care to best suit the infant’s orchild’s capacities with input from all members of thehealth-care team, especially the parents.

Offer treatment within developmentally appropriateframework of the infant or child.

Provide a safe and calm environment with stimuli bestsuited to the infant’s or child’s needs.

Offer the parents realistic plans for the infant or childwith frequent updates.

A thorough assessment offers the best basis for identifica-tion and treatment of confusion.

Parents are best able to provide previous developmentcapacity cues within level of comfort for the infant orchild, thus enhancing likelihood of sense of securityfor all.

Best holistic plan of care reflects expertise of all whichbest know and interact with the infant or child.

In all situations there is greater likelihood of success incare when the infant or child is approached from devel-opmentally appropriate stance to afford a sense ofsecurity.

An environment that is safe and developmentally appro-priate provides freedom from injury while allowing theinfant or child to recover.

Parents will better be able to trust and accept the infant’sor child’s status and caregivers when trusting relation-ships are based on communication that is honest andforthright.


Adult Health


Teach the family about the patient’s condition and how tointeract more effectively with the patient; i.e., provideongoing orientation to surroundings and happeningswithin the family.

Recognize family responses to the patient’s condition,and teach about reasons for condition and how torespond during acute episodes.

Refer to psychiatric-mental health clinical nurse specialist(CNS). Make other referrals to community agencies asneeded, i.e., Alzheimer’s support group, adult day care,Meals-on-Wheels, etc.

Assists the family in understanding changes in thepatient’s orientation, cognition, and behavior. Increasesthe family’s sense of competency in relating to thepatient.

Family members often feel anxious and helplessabout the patient’s behavior. Teaching reasons forthe patient’s condition and how to respond decreasesanxiety and may help decrease the patient’s confu-sion.

The psychiatric-mental health CNS has the expertise tocollaborate with the adult health nurse to plan nursinginterventions for the patient that will help the patientand nursing staff deal with chronic confusion in theacute care setting.



••••••


Provide 30 minutes each shift for the parents to ventilatefeelings about the infant or child.

Identify discharge and follow-up needs with attention toall members of the health-care team.

ChronicOffer resources for support groups and advocacy interest

opportunities.

Explore specific patterns of daily care needs and how bestto offer care within domain of resources available.

Note risk for caregiver role strain due to demandsover time.

Helps reduce anxiety, and offers cues to parental con-cerns.

Support for the parents upon the family’s return to homewill help maintain plan for care and thereby attain ther-apeutic goals.

Specific support groups will assist the parents in dealingwith situation represented by the infant’s or child’sstatus.

Realistic demands will best direct care according to timeand constraints.

Women’s Health

See nursing actions for Adult Health.

Mental Health


Patients taking the following substances: lithium,antianxiety agents, anticholinergics, phenothiazine,barbiturates, methyldopa, disulfiram, alcohol, cocaine,amphetamines, opiates, and hallucinogenics.

Patients experiencing drug withdrawal, electroconvulsivetherapy (ECT) treatments, dementia, dissociative disor-ders, mood disorders, and thought disorders, and eld-erly clients with acute infections such as urinary tractinfections.

Place the client in an environment with appropriate stim-uli. Note level of stimulation and alterations in envi-ronmental stimuli here. For example, specific objects inthe environment that stimulate illusions should beremoved; appropriate lighting, clocks and calendars,and holiday decorations should be used. Refer to day,date, and other orienting information during each inter-action with the client.

Assign the client a room that provides opportunities forcareful observation but is not a chaotic environment.

Place identifying information on the patient and thepatient’s room. Utilize the patient’s preferred name ineach interaction. [Note that name here.]

● N O T E : Mental health clients at risk for this diagnosis include:

Acute

Compendium of psychotropic drugs-fast reference forhealth-care provider.17

Increases patient safety and promotes orientation.18,19

Promotes client safety and decreases environmental stim-uli. High levels of stimuli can increase confusion andhyperactivity.17,20,21

Promotes safety and orientation.




••••••


Mental Health


Protects the client from falls and accidental injury.Clients attempting to free themselves can fall or beinjured on the restraints.18 Promotes client safety.

Promotes client orientation by providing familiar environ-ment.19,20

Decreases ambiguity, prevents information overload, andprovides the time necessary for the client to processinformation, which preserves self-esteem, decreasesanxiety, and improves orientation.22

Promotes client safety. Provides opportunities to reorientthe client to here and now and to ensure clientcomfort.21 Promotes the client’s sense of control.

Promotes safety and the client’s self-esteem by maintain-ing personal control and dignity. Frequent use ofrestraints can encourage clients to assume a passiveapproach to avoid further restraint or as an adaptationto daily use of restraints. At times, physical restraintsmay increase agitation.18,21,23

Promotes client safety, sense of personal control, andself-esteem.19,24 Promotes physical comfort, whichdecreases agitation.

Clients’ touch preferences are very personal. Some clientsmay find it comforting, whereas others may perceive itas an intrusion and respond with increased agitation.21

Antipsychotic medications can increase confusion. Thesemedications can also produce orthostatic hypotension,increasing the client’s fall risk.17,18

Promotes orientation; increases the client’s sense of per-sonal control.

Promotes orientation to the environment and sense of per-sonal control.

Repeated questioning can increase the client’s confusion,and inability to answer questions may have negativeimpact on self-esteem.19,24

Remove harmful objects from the environment. Thiscould include objects in walkways, cords, belts, andraised bedrails or other restraining devices. Duringperiods of increased agitation, one-to-one observationshould be instituted.

Assign primary care nurse each shift. [Note those personshere.]

Communicate with the client using a moderate rateof speech and simple sentences without many ques-tions. Allow time for responding, and avoid indefinitepronouns.

Observe every [number] minutes. Inform the client of thisschedule, and provide the client with written informa-tion as necessary. Provide this schedule in writtenform, i.e., written on a white board in the client’sroom. [Note information necessary for the client here.]

Replace the use of physical restraints with one-to-oneobservation, comfort measures, recliners, appropriatephysical activity, visual barriers, secure unit, lower bedor bed on floor. [Note here those interventions specificto this client.]18

If physical restraints are used, check circulation at leastevery 15 minutes, remove restraint from one limbat a time at least every 2 hours, and provide ROM,opportunities to void, nourishment, brief clear expla-nations about the purpose of the restraint, and infor-mation about when they will be removed during eachinteraction.

Utilize touch as appropriate to the client. [Note theclient’s preferences here.]

Administer antipsychotic medication only if neurologicstatus indicates that this will not increase confusion.

Provide daily routine that closely resembles the client’snormal schedule. [Note that schedule here.]

Provide whatever aids the client needs to adequately per-ceive the environment (hearing or vision). [Note neces-sary aids here and location for storing when not in useby the client.]

Assess mental status through normal interactions with theclient. Do not use formal mental status examinationsunless absolutely necessary. [Note method and sched-ule for assessment here.]



••••••


Limit the client’s choices, and provide information ordirection in brief, simple sentences. Note the level ofthe client’s ability to process information here (e.g., theclient can choose between two items). Support optimalcognitive functioning by: [Note here those interven-tions to be used with this client.]

• Responding to the client’s confused verbalizations(delusions, hallucinations, confabulations, illusions,etc.) in a calm manner

• Utilizing refocusing and/or responding to the feelingsunderlying the content to respond to confused verbal-izations

• Utilizing “I” messages rather than arguments to reori-ent when necessary.

• Providing clothing that is appropriate to time of dayand situation (e.g., night clothes at night and streetclothes during the day)

• Scheduling participation in groups that provide oppor-tunities to remember, review current events, discussseasonal activities, and socialize. [Note here the sched-ule and appropriate groups for this client.]

• Providing measures that promote rest and sleep. [Notehere those measures that are specific for this client withschedule for implementation.]

Provide clear feedback on appropriate behavior. Refer toRisk for Violence if the client is at risk for violentbehavior toward self or others. Assess expectations forbeing realistic with the client’s abilities. [Note limits tobe set here with specific consequences for unwantedbehaviors and specific reinforcers for desired behaviors.]

Provide support system with information about the clientand how to best approach the client. Note here theinformation to be provided and responsible person.

Chronic

Increases orientation while preserving the client’s self-esteem. Large amounts of information provided at onetime can increase confusion and agitation.19,21

Increased anxiety can increase confusion andagitation.19,21

Maintains self-esteem, relieves anxiety, and orients topresent reality.25

Meets the client’s esteem needs by communicatingrespect while providing orientation.19,24,25 Promoteshere-and-now orientation.19

Promotes here-and-now orientation. Provides opportuni-ties to maintain current cognitive skills.19,25

Inadequate sleep can increase confusion and disori-entation.19

Positive reinforcement encourages behavior. Realisticgoals increase opportunities for success, providing pos-itive reinforcement and enhancing self-esteem.

Provides support system with positive coping strategiesthat enhance the client’s functioning.


● N O T E : Mental health clients at risk for this diagnosis include those with Alzheimer’sdisease, Korsakoff’s psychosis, and AIDS dementia. In addition to those interventions foracute confusion, the following interventions are included. It is important to rememberthat the primary difference between these two diagnoses is the irreversibility of the cog-nitive deficits in this diagnosis. It is also important to assess the client for depression,because depression can appear as those illnesses that are related to this diagnosis, espe-cially in elderly clients.

Maintain familiar environment:• Provide objects from the client’s home environment, to

include pictures, personal bedding, personal clothing,music, and other special objects with personal meaning.Note those objects important to the client here, with thenursing actions necessary to maintain the objects.

• Label room with name in large letters and a familiarpicture or item.

Promotes orientation while promoting sense of safety andsecurity.22

Maintains orientation while promoting a sense of per-sonal control by maintaining independence.19,24



••••••


Mental Health


• Provide the same room for the entire hospital stay.Assign primary care personnel. [Note those personshere.]

• Provide structured daily routines, and note the client’sroutine here. This should parallel prehospital routine asmuch as possible.

Provide opportunities for the client to be involved in rem-iniscence, remotivation, current events, socialization,and other groups as appropriate by providing the clientwith assistance needed to get to the groups. [Note theclient’s group schedule here, with the assistanceneeded from nursing staff.]

Spend [number] minutes [number] times a day discussingthe client’s past experiences. This activity can be facili-tated with music, family photographs, and other itemsthat elicit memories. Note the client’s response to thisactivity, and if it appears to increase stress, discon-tinue. The process of this interaction is to provide posi-tive cognitive reframes of past experiences.

Identify and control underlying causes or triggers ofincreased cognitive and behavioral problems. Thiscould include limiting visitors or certain topics of con-versation, increasing rest or providing rest periods dur-ing the day, and ensuring adequate hydration. [Note thespecial adaptations here.]

Utilize nonconfrontational approaches for dealing withbehavior extremes. This could include changing theclient’s context, responding to the feelings beingexpressed, or meeting comfort needs. [Note here thoseresponses that are most effective for the client.]

Spend [number] minutes [number] times a day with theclient doing activities (this should be some activitythe client enjoys and that provides an opportunity forsuccess).

Spend [number] minutes [number] times a day involvedin [type] exercise with the client. (Choose an exercisethe client enjoys and that involves large motor activityif at all possible.)

Retrieve and divert the client when wandering behaviorpresents risk or takes her or him into unobserved areas.

Schedule meetings with the primary care provider beforedischarge to teach effective behavior management tech-niques and develop a plan for care at home. Thisshould include respite for the caregiver. [Note planhere.]

Refer to community agencies that will facilitate ongoingcare. [Note agencies here.]

Maintains orientation by providing continuity of sur-roundings and staff familiar with the client’s needs,perspective, and treatment plan. Excessive stimulationcan exacerbate cognitive or behavioral problems.

Promotes orientation by providing familiarity.18,26

Provide opportunities for clients to interact using currentcognitive skills, which helps decrease anxiety, maintaindignity, and prevent further deterioration and with-drawal.25

Promotes positive reorientation, maintains the client’sdignity, and promotes positive self-esteem. It is impor-tant to note that some clients may have a great deal ofdifficulty coping with past experiences. If this processincreases anxiety, the activity should be discontinued,because high levels of anxiety can increase confusion.

Preserves the client’s dignity and sense of control.26 Eachof these factors can decrease the client’s ability tocope.

Maintains the client’s dignity, and recognizes the limita-tions of cognitive abilities.26

Positive environmental cues from staff have been shownto decrease problematic behaviors in these clients.27

Increased physical activity decreases wandering behaviorand improves the client’s rest.23,27

Decreases the client’s wandering behaviors.27

Facilitates support for caregivers and prevents caregiver“burnout”.19



••••••

Gerontic Health

● N O T E : Aging clients may experience age-related changes in memory to include for-getting specific details but remembering them later, ability to learn new information withsome difficulty in information retrieval, a general awareness of memory impairment, andmemory impairment that does not affect daily life. Causes of confusion should be ruledout upon identification of new onset confusion. Causes may include metabolic diseases,infection, neoplasm, drug side effects, nutritional deficiencies, and cerebrovascularinjury. Alzheimer dementia is possible with new onset confusion and should be ruled outas well.

Goals for clients with confusion may not necessarily need to include reversal ofconfusion. Rather, assisting the confused client and caregiver to feel safe, comfortableand in control is a worthy goal.


Review pertinent laboratory work for possibleimbalances.

Obtain medication list from the client or family of all pre-scribed and over-the-counter (OTC) medications usedby the client.

Decrease extraneous audible–visual input. Provide low-stimuli environment.

Provide orienting cues to the physical layout of the caresite (such as universal symbols for the bathroom, eat-ing area, and the client’s room).

Provide personalized surroundings (familiar pictures,clothing, or mementos).

Use a client photograph to identify personal space.

Address the client by preferred name at each contact.

Introduce self by name at each contact.

Arrange for the family or significant others to be avail-able during periods of increased anxiety or agitation.

Use name and orienting cues in conversations.

Provide physical contact and/or comfort along withverbal interactions.

Explore and explain briefly equipment used in care.

Use familiar objects for activities such as glasses or cupsfor fluids rather than styrofoam cups or paper or plasticcartons.

Assign consistent caregivers.

Limit choices to two in situations where the client mustmake decisions such as dressing or eating.

Provide positive feedback for independent function.

Ensure quiet time or rest periods during the day.

Approach and work with the client in an unhurriedmanner.

Provide information in simple sentences, and allow timefor the client to process information.

Acute confusion may be related to changes in elec-trolytes, glucose, or drug levels.

Medications are a frequent precipitant for acute confu-sion, especially in the very young or old.

Decreases sensory overload and need to cope with acomplex and noisy environment.

Promotes independence.

Promotes identification with self.

Increases connectedness with self. Provides sense ofbelonging.

Reinforces sense of self.

Provides sense of the familiar.

Provides for familiar person in the care setting.

Enhances sense of self and connectedness.

Decreases anxiety generated when trying to cope withthreatening environment. Assists the client in sortingout environment and setting.

Decreases fearfulness.

Decreases complexity of coping with the unfamiliar.

Provides sense of security.

Decreases stress of too many choices.

Promotes self-esteem.

Decreases stress.

Sense of urgency associated with speed perceived asthreatening.

Decreases complexity.




••••••


Gerontic Health


If repetition is needed, repeat information in the exactmanner as originally stated.

Encourage participation in failure-free activities such assinging, exercise, or uncomplicated crafts.

Monitor mental status for changes at least daily and everyshift in acute care setting.

Monitor for increased confusion related to new medica-tion usage.

Chronic (Often Alzheimer dementia)Retrieve and divert the client when wandering behavior

presents risk or takes her or him into unobserved areas.

Assess for expression of intent, “I’m going home now,”and the expression of loss of a valued adult role, “Thechildren need me now.”28

Modify the environment to provide adequate rest, safety,and sleep for the client.28

Provide client with essential sensory aides such asglasses, dentures, and hearing aids.

Avoid chemical and physical restraints.

Schedule and maintain a regular toileting schedule. [Noteschedule here.]

Provide information to all staff that a client is a wanderer.Develop a mechanism for identification and a plan tofollow if a wandering client is missing.28

Use grid-like markings in front of doorways.

Allows for processing of information.

Enhances self-esteem.


Eliminate possible preciptators of confusion.

Prevents possible sensory confusion.28

These can increase confusion and agitation. These do notstop the urge to wander and may exacerbate the urge towander by decreasing the client’s perception of safety.These measures may contribute to client injury.28

Eliminate possible precipitators of confusion andwandering.


May prevent a client from exiting due to a change invisual cues.28

Home Health

● N O T E : Onset of acute confusion may be an emergency requiring immediate referralfor care.


Rule out possible causes of confusion:• Drugs• Hypoxia• Pain or discomfort• Full bladder or urinary tract infection• Bowel impaction• Infection (particularly pulmonary or urinary). Keep in

mind that elder clients may not exhibit typical signs ofinfection.

• Alcohol or benzodiazepine withdrawal• Extreme anxiety

Understanding the cause of confusion determines the bestintervention.


Decisional Conflict (Specify) 463

••••••


Offer explanation and support to the family members andcaregivers.

Encourage the family members and caregivers to maxi-mize communication with the client during lucid inter-vals. Critical information should be exchanged duringthese times.

Help the family members and caregivers identify andcope with impending death if confusion is occurring inthe last hours of life. Terminal confusion, a conditioncommon to impending death, is best treated with mor-phine, chlorpromazine, and scopolamine.29


• Treatment or prevention of underlying problem (sub-stance abuse, infection, pain, or nutritional deficits)

• Providing for rest periods• Providing safe environment• Providing environmental cues to orient the patient (e.g.,

clocks, calendars, photos, familiar objects).• Provide assistive resources as required to include:

• Glasses• Hearing aids• Clocks with large numbers

• Family response to changing behavior and mental sta-tus of the affected person

Assist the family to set criteria to help them determinewhen additional intervention is required, for example,change in baseline behavior.

Refer the patient to appropriate assistive resources asindicated.

Confusion is difficult to cope with at home and can bedistressing to family members.

Some effective communication can still occur if the clientexperiences lucid intervals.

Understanding the cause of confusion determines the bestintervention.

Home-based care requires involvement of the family.Acute confusion disrupts family schedules and rolerelationships. Adjustments in family activities and rolesmay be required.

Decreased vision or hearing acuity may contribute to con-fusion.


Additional assistance may be required for the family tocare for the acutely confused person. Use of readilyavailable resources is cost-effective.

DECISIONAL CONFLICT (SPECIFY)

DEFINITION2

The state of uncertainty about course of action to be takenwhen choice among competing actions involves risk, loss, orchallenge to personal life values.2


1. Verbalization of undesired consequences of alternativeactions being considered

2. Verbalized uncertainty about choices3. Vacillation between alternative choices4. Delayed decision making5. Verbalized feeling of distress while attempting a

decision6. Self-focusing7. Physical signs of distress or tension (e.g., increased

heart rate, increased muscle tension, restlessness)

8. Questioning personal values and beliefs while attempt-ing a decision

RELATED FACTORS2

1. Support system deficit2. Perceived threat to value system3. Multiple or divergent sources of information4. Lack of relevant information5. Unclear personal values or beliefs6. Lack of experience or presence of interference with

decision making


1. Any surgery causing body image change2. Any illness carrying a potential terminal prognosis3. Any chronic disease4. Dementia



••••••


Adult Health


Engage the patient in discussions regarding his or herperception of the problem and information that lends toconflict.

Assist the patient to develop problem-solving processes.Help the patient verbalize alternatives and advantagesand disadvantages of solutions. Help the patient realis-tically appraise situations and set realistic short-termobjectives daily.

Assist the patient in identifying values as necessary.Acknowledge the patient’s values.

Refer to the psychiatric nurse clinician as needed.

Assists the patient to learn to use the problem-solvingprocess.

Helps the patient focus on what is important to self indecision making rather than being concerned aboutpleasing others.

A nurse specialist may be better able to help the patientfocus on the underlying process.

Child Health


Determine who will intervene on behalf of the infant orchild: parents or appointed legal guardian. [Note thatperson here.]

For legal and ethical reasons, it is essential to clarifywhen the parent(s) are unable to assume the parentalrole and obligations and to make this fact known to allinvolved in the child’s care. It is likewise essential forall caregivers to know who is the legal guardian orspokesperson.

5. Traumatic events (natural disasters, significant personalloss)


AnxietyAnxiety is considered to be a feeling of threat that maynot be known by the person as a specific causativefactor. In Decisional Conflict, the patient knows theoptions but cannot decide between specifics.

Deficient KnowledgeIn Deficient Knowledge, the client does not have theinformation to make a decision. In Decisional Conflict,the information is known.

Ineffective Individual CopingThis diagnosis is closely related in that adaptivebehavior and problem-solving abilities are not able tomeet the demands of the client’s needs. Ineffective

Individual Coping and Decisional Conflict may verywell be companion diagnoses.

EXPECTED OUTCOME

Will verbalize at least one concrete personal decision by[date].

Identifies [number] of resources needed to facilitatedecision-making by [date].

Identifies [number] of alternatives by [date].

TARGET DATES

Value clarification, belief examination, and learning deci-sion-making processes will require a considerable length oftime and will require much support. Therefore, target datesin increments of weeks would be most appropriate.



••••••


In instances of conflicting decision makers, ensure thatthe child’s rights are protected according to legalstatutes.

Ensure that appropriate documentation is carried outaccording to situational needs.

Although the child may be ill equipped or unable to par-ticipate fully in decision-making, facilitate develop-mentally appropriate involvement of the child indecision-making. In these interactions, teach the childdecision-making skills.

Be certain that choices or options indeed exist when thechild is allowed to exercise decision-making.

Provide behavioral reinforcement that best fosters learn-ing with appropriate follow-up when the child isinvolved in decisional conflict. [Note behaviors to bereinforced and reinforcers here.]

Explore with the child and support system potential long-term residual effects related to specific decisional con-flict for the child or family.

Irrespective of conflicts in decision making, the infant orchild is entitled to appropriate care. In extreme cases ofconflict, a state or local judge may appoint guardiansor foster parents to assume decision making regardinghealth matters. In other instances (e.g., withholdingsuggested treatment because of religious beliefs), indi-vidual statutes, and precedents must be sought by theparties involved.

Legal documentation according to health care decisionsand related matters is to be carried out as standardcare, with attention to the mandates of the institutionregarding appropriate paper forms to complete.

Early involvement in decision making fosters safe supportfor the child, thereby increasing the likelihood of learn-ing effective coping behaviors. Will also empower thechild and foster a positive self-image.

Preferences and individualization will be realistically val-ued when there is choice or options in the care plan. Itis unethical to indicate there are choices when noneexist (e.g., medication cannot be given by any otherroute but intramuscular).

Appropriate reinforcement will serve to enhance learningand assist the patient in growth in decision-making.

Decision making often has far-reaching effects (e.g., inearly childhood, values of a lifetime are formulated).Appropriate regard to this fact should guide allinvolved in this aspect of child-rearing and supportiveaspects of health care.30

Women’s Health

Unwanted Pregnancy


Provide an atmosphere that encourages the patient toview her options in the event of an unwanted preg-nancy. Assure the patient of confidentiality.

Give clear, concise, complete information to the patient,describing the choices available to her:

• Carrying the pregnancy and keeping the infant• Adoption of the infant• Abortion

Discuss the advantages and disadvantages of each optionwith the patient.

Encourage the patient to discuss beliefs and practices in anonthreatening atmosphere, and include significant oth-ers in the conversation and decision as the patientdesires.

Provides information that allows the patient to make aninformed choice.45




••••••


Women’s Health


Refer the patient to the proper agency for guidance andtreatment.

Discuss and review with the patient the different methodsof birth control.

Assess the patient’s ability to correctly use the differentmethods of birth control.

Provide factual information, listing the advantages anddisadvantages of each method.

Provide the patient information on obtaining her methodof choice.

Explore with the patient and significant other their viewson children and family.

Provides information and support to assist the patient inplanning future pregnancies.31

Women’s Health

Less-Than-Perfect Infant

● N O T E : Families faced with the birth of a child with congenital anomalies or devel-opmental defects experience decisional conflict and great confusion about choices thatneed to be made. Often there is a sense of urgency, because decisions need to be madequickly to save the life of the infant. Many times the infant was delivered by cesareansection, and it is the mother’s partner who, alone, must often make crucial decisions thatcould affect the family and the life of the infant. Parents experience not only confusion,fear, guilt, and helplessness, but also feelings of inadequacy as parents.


Provide accurate information to the parents as soon aspossible.

Stillborn or Fetal DemiseLet the parents see and hold the infant if at all possible.

Support the parents in their grieving process for the lossof the perfect infant, and perhaps the death of theinfant.34,35

Keep the parents informed continuously, and encouragethe health-care team to talk to them often.

Contact significant persons, of the parents’ choice, whocan come and be of support to them.36

Give the parents a private place to be with their supportpersons.

Encourage the parents to visit the infant in the neonatalintensive care unit (NICU) as often as possible.

Collaborate with NICU staff to plan activities that allowthe mother and infant to spend as much time togetheras much as possible.

Refer to support groups and agencies as needed forfollow-up care when leaving hospital.37,38

Provides information and supportive environment thathelps the parents make decisions.32,33

Promotes bonding and provides comfort for both the par-ents and infant.

Support is essential in resolving decisional conflict.



••••••

Mental Health

● N O T E : The client who is experiencing a decisional conflict is faced with confusionabout alternative solutions. When assisting these clients, the nurse should be careful notto connote the client’s confusion negatively. Various authors39–41 have supported thepositive role confusion plays in the change process. Erickson39 frequently encouragedconfusion as a way to distract the conscious mind and allow the unconscious to developsolutions. It is from this theoretical base that the following interventions are developed.


Assure the client that the difficulty he or she is experienc-ing in decision-making is positive in that it has placedhim or her in a position to look for new creative solu-tions. If he or she were not experiencing this difficulty,he or she might be tempted to remain in the same oldproblem solution set.

Assist the client in reducing the pressure of time on mak-ing a decision.

Have the client explain the time he or she has given him-or herself to make a decision. Asking the client the fol-lowing question may assist in this process: “What isthe worst that will happen if a decision is not maderight now?”

Sit with the client for [number] minutes twice per day todiscuss the information and perceptions she or he hasregarding the current situation and possible solutions.As the client explores the situation, the remaininginterventions can be added to these discussions.

Have the client explore feelings related to the choices andthe information related to the choices. This processmay extend over several days. The client may be reluc-tant to verbalize negative feelings related to certainchoices if a trusting relationship has not yet beendeveloped with the nurse.

Have the client discuss how significant others think andfeel about the various choices. Have the client evaluatethe impact of the feelings of significant others on his orher decision-making process.

Have the client fantasize an ideal choice.

Have the client construct a list of solutions (at least 20)that would produce the ideal choice. (These solutionsare not to be evaluated at this time.) Encourage theclient to develop some unrealistic solutions. This maybe promoted by asking the client what he or she mighttell a friend to do in this situation or by having theclient generate three magic-wish solutions (e.g., “Ifyou had a magic wand, what would you do to resolvethis situation?”)

Sort through developed list with the client generating solu-tions from the ones listed. At this time, the client canbegin to combine and eliminate ideas after evaluation.Carefully evaluate each solution before it is eliminated.What appears to be a bizarre solution can become usefulwhen altered or combined with another idea.

Promotes positive orientation, self-worth, and hope.

Provides time to develop alternative problem solutions,and decreases stress on the client.

Aids in understanding the client’s perception of thesituation.

The client’s cognitive style and feelings about the situa-tion affect his or her appraisal of both the situation andpossible solutions.42

Support system involvement increases the probability ofpositive outcomes.

Accesses creative problem solutions that bypass theclient’s self-imposed limits.




••••••


Mental Health


As each idea is evaluated, provide all information neces-sary to evaluate the idea.

Explore the client’s thoughts and feelings about each idea.Remind the client that there are no perfect answers and

that each of us makes the best choice that can be madeat the time.

Remind the client that if a choice that is made doesnot resolve the problem, alternative solutions canthen be tried.

Remind the client that a solution that does not workprovides more information about the problem thatcan be used in developing future solutions.

Meet with the client and support system to allow thesupport system to be a part of the decision-makingprocess, if appropriate.

Discuss with the client and support system any secondarygains from not making a decision.

Once a decision is made, have the client develop a behav-ioral plan for implementation. [Note that plan here.]

Aids in assessing the client’s commitment to each possi-ble solution.

Promotes positive orientation, self-worth, and hope forthe future.

Promotes positive orientation.

Support system involvement increases the probability ofpositive outcome.

Assesses for positive reinforcement for not resolvingproblem.

Having a plan to cope with the anticipated situations pro-motes a perception of greater control over future situa-tions and increases the probability of the client’senacting new coping behaviors.

Gerontic Health

In addition to the following interventions, the interventions for Adult Health can be applied to the aging client. Decision-making capacity is defined as possessing a set of values and goals, being able to communicate and understand informa-tion, and having the ability to reason and deliberate about one’s choices.43 The mere presence of aging should not implyimpaired decision-making capacity. In the absence of dementia, older adults are usually capable of adequate decision-making independently or with assistance.


Discuss with the patient prior examples of DecisionalConflict and their outcomes.

Assess for the presence of dementia

Assess for the presence of legal documents grantingdurable power of attorney for health care in newclients.

Emphasizes ability to problem solve, and reinforcessuccesses.

May affect the client’s ability to make sound decisions.

Surrogate decision makers may already be in place.

Home Health


Teach the client and family measures to decreaseDecisional Conflict:

• Providing appropriate health information• Joining a support group• Clarifying values• Performing stress reduction activities

Appropriate knowledge and values clarification betweenthe client and family will reduce conflict.


Environmental Interpretation Syndrome, Impaired 469

••••••


• Seeking spiritual or legal assistance as needed• Identifying useful sources of information

Assist the client and family in identifying risk factorspertinent to the situation:

• Lack of knowledge• Developmental or situational crisis• Role confusion• Excess stress• Excess stimuli

Answer questions about a terminal diagnosis and progno-sis with honesty and sensitivity.

Consult with or refer the patient to appropriate assistiveresources as indicated.

Early identification of risk factors provides opportunityfor early intervention.

Develops trusting relationship, and helps clients makewell-informed decisions.

Use of the network of existing community services pro-vides for effective utilization of resources.

ENVIRONMENTAL INTERPRETATIONSYNDROME, IMPAIRED

DEFINITION2

Consistent lack of orientation to person, place, time, or cir-cumstances over more than 3 to 6 months, necessitating aprotective environment.


1. Chronic confusional state2. Consistent disorientation in known and unknown envi-

ronments3. Loss of occupation or social functioning from memory

decline4. Slow in responding to questions5. Inability to follow simple direction, instructions6. Inability to concentrate7. Inability to reason

RELATED FACTORS2

1. Depression2. Huntington’s disease3. Dementia (e.g., Alzheimer’s disease, multi-infarct

dementia, Pick’s disease, AIDS, alcoholism, Parkinson’sdisease)

4. Alcoholism5. Parkinson’s disease


See Related Factors.


There are several diagnoses that interface with thisdiagnosis (e.g., Impaired Memory, Disturbed ThoughtProcess, or Confusion). This diagnosis refers to along-term problem (3 to 6 months) that results in thepatient’s having to be admitted to a protective envi-ronment. This diagnosis predominantly relates to anend result of the other diagnoses.

EXPECTED OUTCOME

Will have decreased episodes of environmental confusion by[date].

Identifies [self, environment, month, significant other]by [date].

Caregivers verbalize [number] environmental safetymeasures needed by [date].

TARGET DATES

This is a long-term diagnosis, so an appropriate target datewould be expressed in terms of weeks or months.


Adult Health

● N O T E : These Actions/Interventions and Rationales are essentially the same as thosefor Chronic Confusion.




••••••

Child Health

This diagnosis may present in children also. If so, the same basic plan of care as that of adults should be implemented,with attention to safe, developmentally appropriate interventions.


Monitor for parental–infant reciprocity to determinenature of parent–infant or parent–child relationship.

When there may be a genetic concern, offer appropriatecounseling.

Offer [number] minutes each shift for the parents to ven-tilate specific concerns regarding the infant or child.

Explore all contributing factors, especially underlyingmedical status or deviation in behavior.

Provided environmental adaptations to protect from self-injury. [Note those adaptations necessary here.]

Provide routine of care with attention to caregiver(s)input.

Seek assistance from primary care health team members,especially pediatric psychiatrist, child life specialist,and pediatrician, as appropriate.

Reciprocity will offer cues as to what match does or doesnot exist in the relationship.

When a genetic component exists, there is an obligationfor present and futuristic planning by all involved.

Offers reduction in anxiety, plus an opportunity to noteparental concerns.

Provides a comprehensive base for plan.

Provides anticipatory safety.

Values parental input.

Satisfies need for special care.


Adult Health


Identify self and the patient by name at each interaction.

Speak slowly and clearly in short, simple words and sen-tences.

When the patient is delusional, focus on underlying feel-ings and reinforce reality (have clocks, calendars, etc.on the wall). Do not argue with the patient.

If the patient becomes aggressive, focus on underlyingfeelings and attempt to refocus interaction on topicsmore acceptable and/or less threatening to the patient.

Keep the patient’s room well lighted. Maintain a calmenvironment.

Teach the family about the patient’s condition and how tointeract more effectively with the patient; i.e., provideongoing orientation to surroundings and happeningswithin the family.

Refer to psychiatric–mental health CNS. Make otherreferrals to community agencies as needed, i.e.,Alzheimer’s support group, adult day care, Meals-on-Wheels, etc.

Short-term memory loss necessitates frequent orientationto person, time, and environment.

Allows time for information processing, and avoids useof complex statements and abstract ideas.

Recognizing and acknowledging feelings may decreasethe client’s anxiety and give a sense of being under-stood. Arguing may increase the patient’s anxiety andreinforce intensity delusions.44

Focusing on feelings increases the patient’s feelings ofbeing understood, and discussing nonthreatening topicsincreases the patient’s sense of competency and self-esteem.

Decreases possibility of environmental sensory misrepre-sentations, and helps meet patient safety needs.

Assists the family in understanding changes in thepatient’s orientation, cognition, and behavior. Increasesthe family’s sense of competency in relating to thepatient.

The psychiatric-mental health CNS has the expertise tocollaborate with the adult health nurse to plan nursinginterventions for the patient that will help the patientand nursing staff deal with chronic confusion in theacute care setting.



••••••

Women’s Health

See Adult Health nursing actions.

Mental Health


Monitor the client’s level of anxiety and refer to Anxiety(Chapter 8) for detailed interventions related to thisdiagnosis.

Place the client in an environment with appropriate stim-uli. Note level of stimulation and alterations in envi-ronmental stimuli here; i.e., specific objects in theenvironment that stimulate illusions should beremoved, and appropriate lighting, clocks, calendars,and holiday decorations should be provided. Refer today, date, and other orientating information duringeach interaction with the client.

Place identifying information on the patient and thepatient’s room. Utilize the client’s preferred name ineach interaction. [Note that name here.]

Remove harmful objects from the environment. Thiscould include objects in walkways, cords, belts, andraised bedrails or other restraining devices. Note herespecial precautions for this client.

Assign primary care nurse each shift. Note those personshere.

Observe every [number] minutes. Inform the client of thisschedule, and provide the client with written informa-tion as necessary. Note information necessary for theclient here. If the client is depressed, this observationmay be increased because of increased risk for self-harm. Refer to Risk for Violence (Chapter 9) for spe-cific interventions.

Provide daily routine that closely resembles the client’snormal schedule. [Note that schedule here.]

Assess mental status through normal interactions with theclient. Do not use formal mental status examinationsunless absolutely necessary. [Note here method andschedule for assessment.]

Limit the client’s choices, and provide information ordirection in brief, simple sentences. [Note here thelevel of the client’s ability to process information (e.g.,the client can choose between two items).]

Keep initial interactions short but frequent. Speak to theclient in brief, clear sentences. [Note frequency andlength of interactions here.]

Utilize “I” messages, rather than argument, to reorientwhen necessary.

Respond to confused verbalizations by responding to thefeelings being expressed.

Increased anxiety can negatively impact memory and ori-entation and contribute to further deficits.

Increases patient safety and promotes orientation.

Provides safety and promotes orientation.

Protects the client from falls and accidental injury.

Promotes client orientation by providing familiarenvironment.

Promotes client safety. Provides opportunities to reorientthe client to here and now and to ensure client comfort.Promotes the client’s sense of control.

Promotes orientation, and increases the client’s sense ofpersonal control and orientation.

Repeated questioning can increase the client’s confusion,and inability to answer questions may have negativeimpact on self-esteem.

High levels of stimulation can increase confusion, andinability to make choices may have negative impact onthe client’s self-esteem.

Too much information can increase the client’s confusionand disorganization.

Meets the client’s esteem needs by communicatingrespect while providing orientation. Promotes here-and-now orientation.

Maintains self-esteem, relieves anxiety, and orients topresent reality.




••••••


Mental Health


When the client’s ability to tolerate more complex situa-tions increases, schedule his or her participation ingroups that provide opportunities to remember, reviewcurrent events, discuss seasonal activities, and social-ize. [Note here the schedule and appropriate groups forthis client.]

Provide clear feedback on appropriate behavior. Setbehavior goals that the client can achieve. [Note herethe behaviors that are to be rewarded and the rewardsthat are to be given.]

Spend [number] minutes [number] times a day involvedin exercise with the client. (Choose exercise the clientenjoys and that involves large motor activity if at allpossible.) [Note the specific activity here.]

Spend [number] minutes [number] times per week pro-viding information to the client’s support system. Notespecific information to be provided and person respon-sible for this activity here.

Refer to community agencies that will provide ongoingmonitoring of client’s condition and support for care-givers.

Promotes here-and-now orientation. Provides opportuni-ties to maintain current cognitive skills.

Positive reinforcement encourages behavior. Realisticgoals increase opportunities for success, providing pos-itive reinforcement and enhancing self-esteem.

Improves rest and increases natural endorphins.

Family and client involvement enhances effectiveness ofintervention and promotes community support.

Gerontic Health

In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.


Review mental status examination to identify areas ofstrengths and needs.

Survey current environment for potential unsafe areas.

Adapt the environment to decrease risk for injury (e.g.,access to exits, thermal injury potential, or ingestion ofharmful substances).

Instruct the caregiver in environmental adaptations to pro-vide protective environment.

Use labeling or pictorial symbols to indicate specificareas or conveniences (such as universal symbols forfood or restrooms or pictures to indicate the client’sroom).

Ensure identification of the client (ID bracelet ornecklace).

Provide conversational cues to person, place, and time.

Retrieve and divert the client when wandering behaviorpresents risk or takes her or him into unobserved areas.

Depending on examination used, may indicate the client’sability to read, interpret symbols, or process simpleversus complex instructions.

Correcting unsafe areas decreases potential for clientinjury.

Assists the client to interpret environment.

Provides means of identification in the event the clientleaves the care setting.

Presents information in a nonthreatening manner.




••••••

Home Health

In addition to the following interventions, the interventions for Adult Health can be applied with the home health client.



• Provide a consistent care provider.• Provide for consistent daily schedule with structured

activities.• Have the client wear identification bracelet; put name

in clothing.• Provide safe environment.• Provide environmental cues to orient the patient (e.g.,

clocks or calendars).• Provide assistive resources as required.

• Monitor family response to changing behavior andmental status of the affected person.

Assist the family to set criteria to help them determinewhen additional intervention is required; for example,help them to recognize signals indicating a change intheir ability to maintain a safe environment.

Offer support to the caregivers and family members:• Teaching about management of behavior• Self-care strategies• Community resources


Home-based care requires involvement of the family.Impaired interpretation of the environment disruptsfamily schedules and role relationships. Adjustments infamily activities and roles may be required.

Decreased vision or hearing acuity may contribute to con-fusion.


Promotes adaptive coping.

Additional assistance may be required for the familyto care for the family member with Impaired Environ-mental Interpretive Syndrome.


Assess for expression of intent, “I’m going home now,”and the expression of loss of a valued adult role, “Thechildren need me now.”28

Modify the environment to provide adequate rest, safety,and sleep for the client.28

Provide client with essential sensory aides such asglasses, dentures, and hearing aids.

Avoid chemical and physical restraints.

Schedule and maintain a regular toileting schedule. [Noteschedule here.]

Provide information to all staff that a client is a wanderer.Develop a mechanism for identification and a plan tofollow if a wandering client is missing.28

Use grid like markings in front of doorways.

Eliminate possible preciptators of confusion.

Prevents possible sensory confusion.28

These can increase confusion and agitation. These do notstop the urge to wander and may exacerbate the urge towander by decreasing the client’s perception of safety.These measures may contribute to client injury.28

Eliminate possible precipitators of confusion andwandering.


May prevent a client from exiting due to a change invisual cues.28


KNOWLEDGE, DEFICIENT (SPECIFY)

DEFINITION2

Absence or deficiency of cognitive information related tospecific topic.2


1. Verbalization of the problem2. Inappropriate or exaggerated behaviors (e.g., hysterical,

hostile, agitated, or apathetic)3. Inaccurate follow-through of instruction4. Inaccurate performance of test

RELATED FACTORS2

1. Cognitive limitation2. Information misinterpretation3. Lack of exposure4. Lack of interest in learning5. Lack of recall6. Unfamiliarity with information resources


1. Any diagnosis that is entirely new to the patient2. Mental retardation3. Post head injury4. Depression5. Dementia6. Chronic illness that client is having difficulty

managing


NoncomplianceIn Noncompliance, the patient can return-demonstrateskills accurately or verbalize the regimen needed, butdoes not follow through on the care.

Disturbed Thought ProcessThis diagnosis would be evident by lack of immediaterecall on return-demonstration rather than inaccurateor limited demonstration and recall.

PowerlessnessThis diagnosis would be reflected by statements suchas “How will this help?”, “I have no control over this,”“I have to rely on others” rather than statementsrelated to “I don’t really understand,” “I’m not reallysure how,” or “Is this right?”

Ineffective Health MaintenanceIneffective Health Maintenance may include DeficientKnowledge, but is broader in scope and includes suchaspects as limited resources and mobility factors.

EXPECTED OUTCOME

Will return-demonstrate [specific knowledge deficit activity]by [date].

TARGET DATES

Individual learning curves vary significantly. A target dateranging from 3 to 7 days could be appropriate based on theindividual’s previous experience with this material, educa-tion level, potential for learning, and energy level.


••••••


Adult Health


Identify how the patient perceives the impact of thesituation.

Identify the patient’s best methods for learning.

Initiate teaching when patient is most amenable to receiv-ing information (rested, reduced anxiety, pain relief, etc.)

Provide relevant information only.

Provide an environment conducive to learning.

Design teaching plan specific to the patient’s deficit areaand specific to the patient’s level of education. Includesignificant others in teaching sessions. [Note specificplan here.]

Adult learning principles indicate that adult learners bet-ter relate to information that is directly pertinent totheir situation.

Provides new knowledge based on the patient’s perceivedneeds. Individuals learn in their own way and in theirown time frame. Motivates learning and provides sup-port and reinforcement for learning.


Knowledge Deficient (specify) 475

••••••


Explain each procedure as it is being done, and give therationale for procedure and the patient’s role.

Provide positive reinforcement as often as possible forthe patient’s progress.

Have the patient restate, in his or her own words, cogni-tive materials during teaching session. Have repeat oneach subsequent day until discharge.

Ensure that basic needs are taken care of before andimmediately after teaching sessions.

Pace teaching according to the patient’s rate of learningand preference during teaching session.

Provide the patient with ample opportunity to askquestions.

Collaborate with and refer the patient to appropriateassistive resources.

Incorporates another teaching method; reduces anxiety,thus promoting learning.

Reinforces learning achieved and promotes positive ori-entation.

Repeated practice of a behavior internalizes and personal-izes the behavior.44

Prevents distractions during teaching session due to basicneeds not being met.

Considers the patient’s learning style and ability toprocess new information.

Coordinates team approach to health and provides meansto follow up and reinforce learning.

Child Health


Determine whether there are ambiguities in the minds ofthe parents or child.

Identify the learning capacity for the patient and family.

Determine the scope and appropriate presentation for thepatient and family based on previous actions, plusdevelopmental crises for each. Do not overwhelm thepatient. [Note adaptations needed based on clientneed.]

Evaluate the effectiveness of the teaching-learning experi-ence by:

• Brief verbal discourse to provide concrete data• Brief written examination to show progress• Observation of skills critical for care (e.g., change of

dressing according to sterile technique)• Allowing the child to perform skills in general fashion

with use of dolls

Clarification and verification will ensure a greater likeli-hood of understanding and valuing aspects critical topatient teaching.

Realistic capacity for learning should be a primary factorin patient teaching, because it serves as one majorparameter in expectations of learning.

Developmental needs of all involved will best serve as anessential framework for teaching the patient and fam-ily. Potentials and capacity for use of all the sensory-perceptual aspects of cognition should be exploredand used to ensure the best opportunity for effectiveteaching.

Evaluation is an indicator of both teaching effectivenessand learning. It serves as another essential aspect ofpatient teaching, with the appropriate focus on individ-ualization, by pointing out areas needing reteaching.

Women’s Health


Teach normal physiologic changes the new mother canexpect postpartum:

• Lochia flow• Breast changes

Provides information to assist new mothers in postpartumadaptation and transition to motherhood.46,47




••••••


Women’s Health


• Breastfeeding: Engorgement, comfort measures,clothing, positions for mother and infant comfort andhygiene (see actions for the Nutrition diagnoses inChapter 3).

• Non-breastfeeding: Suppression of lactation (medica-tions, clothing such as tight-fitting bra, and comfortmeasures); importance of holding the baby while bot-tle-feeding (NEVER prop bottle and do burp the babyoften); formulas (different kinds and preparation).

• Perineum and rectum: episiotomy, hemorrhoids,hygiene, medications, and comfort measures

Demonstrate infant care to new parents:• Bathing• Feeding• Cord care• Holding, carrying, etc.• Safety• Sleep–wake states of the infant

Provide quiet, supportive atmosphere for interaction withthe infant to allow the parent to:

• Become acquainted with infant• Practice caretaking activities such as breastfeeding or

formula feeding• Begin integration of the infant into the family

Discuss infant care, taking into consideration age and cul-tural differences of the parents:

• Teenagers: Involve significant others. Have the motherreturn-demonstrate infant care. Refer to support sys-tems such as Young Parent Services and church groups.

• First-time older mothers: Allow verbalization of fears.Involve significant others. Provide encouragement.

Adjust teaching to take into consideration different cul-tural caretaking activities, such as preventing the evileye in the Hispanic culture, or the mother not holdingthe baby for several days immediately after birth insome Far Eastern Indian cultures.

Demonstrate newborn skills to the parents. Utilize differ-ent assessment skills to teach the parents about theirnewborn’s capabilities—gestational age assessment,physical examination of newborn, or BrazeltonNeonatal Assessment Scale (sleep–wake states).

Encourage the parents to hold and talk to the newborn.

Discuss different methods of birth control and the advan-tages and disadvantages of each method:

Stress during the postpartum period is physical, intraper-sonal and interpersonal, research suggests that breast-feeding can reduce stress by protecting the motherfrom environmental stimuli.48

Breast binding should be discontinued as a means of lac-tation suppression as research shows that supportivebras are more effective.49

Assists new parents in adapting to parenting role. Allowsthe parents to practice new skills in a nonthreateningenvironment and seek clarification from an informedsource.50–54

Promotes positive learning experience for the mother,father, and baby.50–54

Helps the parents gain confidence when caring for thenewborn. Provides opportunity for nurse to teach andreinforce teaching.50–54

Informs the new mother (parents) of choices in birth con-trol methods, and gives them the opportunity to askquestions.


Knowledge, Deficient (Specify) 477

••••••


• Chemical: spermicides and pills• Mechanical: condom, diaphragm, intrauterine device

(IUD)• Behavioral: abstinence, temperature-ovulation-cervical

mucus (Billing’s method), or coitus interruptus• Sterilization: vasectomy, tubal ligation, or hysterec-

tomy

Discuss signs and symptoms of perimenopausal andmenopausal changes with the woman: hot flashes, per-spiration, and/or chilly sensations; numbness or tin-gling of skin; insomnia or restlessness; interruptedsleep; feelings of irritability, anxiety, or apprehension;feeling depressed or unhappy; sensations of dizzinessor swimming in the head; feeling of weariness of mindand body associated with desire for rest; joint or mus-cle pain; headaches; quickening or acceleration ofheartbeat; and sensation of “crawly skin” (feels likeinsects creeping over skin).55–57

Clients who are informed and active participants in theirown health decisions, in collaboration with the healthcare provider who can provide a screening of hormonelevels, can relieve some of the symptoms ofmenopause.

Mental Health


Ask the client about previous learning experiences ingeneral and about those related to the current area ofconcern (e.g., has the client learned that he or she is apoor learner, that he or she does not have the intellec-tual ability to learn the type of information that is cur-rently required, or that the smallest mistake in theactivity to be learned could be fatal?)

Monitor the client’s current level of anxiety. If level ofanxiety will inhibit learning, assist the client with anxi-ety reduction. (Refer to Anxiety in Chapter 8 fordetailed interventions.)

Determine what the client thinks is most important in thecurrent situation.

Assist the client in meeting those needs that representlower-level needs on Maslow’s hierarchy so attentioncan be focused on the area of learning to be addressed(e.g., if the client is concerned that children are notbeing cared for while he or she is hospitalized, he orshe may not be able to focus on learning). [List theneeds to be met here.]

Sit with the client for [number] minutes 2 times each dayto discuss the following (each discussion point can beadded as appropriate to the client’s situation):

• Have the client describe those issues that are mostimportant for them to address.

Helps determine aspects of the client’s cognitive appraisalthat could impact learning.

Severe anxiety and impaired cognitive functioning candecrease the client’s ability to attend to the environ-ment in a manner that facilitates learning.

The client’s cognitive appraisal can impact his or herwillingness to attend to the information. This is espe-cially true of adult learners. Change is dependant onthe client’s perception of the problem.58

Promotes attention to learning. Reduces anxiety.

Facilitates client change and understanding by addressingthe client’s perceptions of need. When information ispresented when the client is ready in a way that ismeaningful for the client, it has greater impact.58,59

Change is dependant on client’s perception of theproblem.58




••••••


Mental Health


• Provide all information in a format that is meaningfulto the client. This includes careful selection of lan-guage and of the information provided.

• Provide successive information based on client’sresponse to previous information presented.

Provide positive, informative verbal reinforcement for theclient’s efforts to learn. [Note here those statementsthat are reinforcing for this client.]

Establish learning goals with the client that ensure suc-cess. [Note those goals here.]

Establish time to include significant others in the learningexperiences. During this interaction, address the con-cerns of these support systems. [Note schedule hereand those to be included.]

Include the client in group learning experiences (e.g.,medication groups).

Refer client and support system to community agenciesthat will provide ongoing support for learning. [Notethose agencies here.]

Positive reinforcement increases behavior.

Success provides positive reinforcement and promotescontinued learning efforts.

A change in one part of the system affects the whole sys-tem. If the intervention is developed with the input ofsignificant others, then it has meaning to this supportsystem.58,59

Provides the client with opportunity to learn fromothers and to discuss new coping behaviors in asafe environment.

Gerontic Health


● N O T E : Aging clients are able to learn new material readily but may experiencedifficulty with information retrieval. This should be considered when teaching elderlyclients.


Determine current knowledge base by interviewing thepatient and have the patient state current knowledgeregarding condition.

Ensure that glasses and hearing aids, if needed, are func-tioning and used.

Encourage the patient to set the pace of the teachingsessions.59

Monitor for fatigue.

Present small pieces of information in each session.Use examples that can be related to the individual’s life

and lifestyle.Determine whether there is increased anxiety during

teaching sessions (e.g., watch body language). If so,use relaxation techniques prior to session.

Use audiovisual aids that are appropriate for the individualin regard to print size, colors, volume, and tone pitch.

Use repetition with positive feedback for correctresponses.

Provides a stepping-stone to pieces of information thatmay be incorrect or lacking.

Enhances communication process.

Assists in keeping sessions focused on the patient’s abil-ity to acquire new information.

Fatigue interferes with concentration and thus decreaseslearning.

Avoids overwhelming the patient. Promotes learning.Adds realism to information, and makes transferring of

information easier.Anxiety decreases concentration and ability to learn.

Promotes visual and sensory input according to the indi-vidual’s needs.

Reinforces learning and allows evaluation of learning.


Knowledge, Readiness For Enhanced 479

••••••

Home Health

● N O T E : Many of the interactions between clients, families, and the nurse during thecourse of home health care are related to health education. Proper assessment by thenurse of the potential for or actual knowledge deficit is imperative. The nurse should usetechniques based on learning theory to design teaching interventions that will be appro-priate to the situation at hand. These techniques include, but are not limited to, usingteaching materials that match the readiness of the participant, repeating the materialusing several senses, reinforcing the learner’s progress, using a positive and enthusias-tic approach, and decreasing barriers to learning, for example, language, pain, or phys-ical illness.


Teach the client and family measures to reduce knowl-edge deficit by seeking the following information andlearning conditions:

• Information regarding disease process• Rationale for treatment interventions• Techniques for improving learning situation [motiva-

tion, teaching materials that match cognitive level ofparticipants, reduction of discomfort (e.g., control ofpain and use of familiar surroundings)]

• Enhancement of self-care capabilities• Written materials to supplement oral teaching (i.e.,

written materials that are appropriate to cognitive leveland to self-care management)

• Addressing client and family questions

Coordinate the teaching activities of other health care pro-fessionals who may be involved. Reinforce the teachingof ROM by the physical therapist, for example.

Involve the client and family in planning, implementing,and promoting reduction in knowledge deficit:

• Family conference• Mutual goal setting• Communication• Family members responsible for specific tasks or infor-

mation

Consult with or refer to assistive resources as indicated.

Conditions that support learning will decrease deficit.Provides the client and family with necessaryinformation.

Coordination reduces duplication and enhances planning.Provides an opportunity for health care professionals toclarify any conflicting information before sharing itwith the client.


Use of the network of existing community services pro-vides for effective utilization of resources.

KNOWLEDGE, READINESS FORENHANCED

DEFINITION2

The presence of acquisition of cognitive information relatedto a specific topic is sufficient for meeting health relatedgoals and can be strengthened.


1. Expresses an interest in learning2. Explains knowledge of the topic3. Behaviors congruent with expressed knowledge4. Describes previous experiences pertaining to the topic


Knowledge, DeficientDeficient Knowledge is utilized when the client cur-rently does not have the knowledge necessary tomanage a health care situation or meet desiredhealth-care goals.

Knowledge, Readiness for EnhancedReadiness for Enhanced Knowledge would be thecorrect diagnosis when the client has sufficient infor-mation to meet health-care goals but has a desire/need to have this information enhanced.


EXPECTED OUTCOME

The client will verbalize enhanced knowledge of [topic] by[date].


••••••


Adult Health


Collaborate with the patient to identify areas that requirefurther development. Set realistic and achievable goals.

Refer the patient to reliable health resources.

Provide the patient with requested information [Noteinformation needed and plan for presentation here.]

Meet with the patient [weekly/daily] to evaluate progressand need for adaptation of plan.

Child Health


Determine learning needs and focus on developmentallyappropriate method. [Note method to be used for thischild here.]

Determine goals for health-related requisite knowledgewith inclusion of parents.

Provide appropriate tools and models for teaching. Forexample, flow meter for asthmatic training, or insulin,syringes, and guidelines for plan for diabetes client andfamily.

Monitor for follow-up. Use appropriate technique toaccurately ascertain required information. For example,how to perform peak flow meter demo or administeraccurate dosage of insulin subcutaneously with aseptictechnique.

Teach the patient and family when to seek assistance orto report to primary care pediatrician.

Facilitate adaptation of plan for long-term needs withspecific attention to possible school nursing assistanceor a setting other than home.

Provide opportunities to meet with other children experi-encing similar health-care needs.

Assist in identification of how the usual daily routine maybe maintained with incorporation of essential health-care regimen.

Provide reinforcement for success in meeting goals andcompliance with the expected health-care regimen.[Note reinforcement plan for this client here.]

Ensures realistic approach for child and parents.

Sets relevant focus for learning.

Offers realistic opportunity for practice in supportiveenvironment

Validates appropriate knowledge and application.

Offers anticipatory guidance.

Provides realistic planning of health plan.

Engenders a sense of peer support to afford a sense ofshared affiliation.

Provides realistic anticipatory planning.

Values and enhances learning with empowerment forfuture success.

TARGET DATESSince this is a positive diagnosis involving teaching as a pri-mary intervention a target date of 1 to 2 days after diagnosisis preferred.


Knowledge, Readiness For Enhanced 481

••••••

Women’s Health

These would be the same as for Adult Health except for the following:

A C T I O N S / I N T E R V E N T I O N S R AT I O N A L E

Women teach other women, and have been viewed ashealers throughout history.

Provide women with information about tests and screen-ings that will prevent health-care problems.

Research has shown that women are more open to alter-native methods of health and healing.60

Women will seek out information and care for theirhealth-care needs.61

Gerontic Health


Determine the client’s priorities and preferred learningstyle.

Monitor physical changes that may impact learning(visual changes, hearing loss, memory impairment).

Assist the patient in setting realistic goals for learning.

Provide an environment conducive to learning:• Maintain a comfortable temperature.• Ensure the client is not hungry, in pain, or sleepy.• Have a family member present if desired or needed.• Use real equipment when possible to facilitate under-

standing.• Keep the session short, factual, and to the point.• Use common vocabulary and avoid the use of medical

jargon.

Provide referral as needed to include:• Enterostomal therapist• Dietician• Physical therapy• Occupational therapy

Utilize adult teaching principles during educationalsessions:

• Focus on information that is important to the client.• Use teaching materials that appeal to many types of

learners (visual, auditory, kinesthetic).

Allow the nurse to focus on what is relevant to client andprovide teaching that is best received by the client.

This allows the nurse to make needed accommodationswhen teaching.

Client will not become discouraged by unrealistic goals.

Maximizes the effectiveness of teaching and learning.

Use of the interdisciplinary team facilitates most compre-hensive and accurate information and assistance for theclient.


Mental Health

Refer to nursing interventions for Knowledge, Deficient, Mental Health to assist client in addressing knowledge needs.



Spend [number] minutes per shift to discuss the client’spriorities and preferred learning style.

Monitor physical changes that may impact learning(visual changes, hearing loss, memory impairment).

Allow the nurse to focus on what is relevant to client andprovide teaching that is best received by the client.

This allows the nurse to make needed accommodationswhen teaching.



MEMORY, IMPAIRED

DEFINITION2

Inability to remember or recall bits of information or behav-ioral skills.*


1. Inability to recall factual information2. Inability to recall recent or past events3. Inability to learn or retain new skills or information4. Inability to determine whether a behavior was performed5. Observed or reported experiences of forgetting6. Inability to perform a previously learned skill7. Forgets to perform a behavior at a scheduled time

RELATED FACTORS2

1. Fluid and electrolyte imbalance2. Neurologic disturbances3. Excessive environmental disturbances4. Anemia5. Acute or chronic hypoxia6. Decreased cardiac output


1. Hypoxia2. Anemia3. Congestive heart failure4. Alzheimer’s disease


••••••




Assist the patient in setting realistic goals for learning.

Provide an environment conducive to learning:• Minimize distractions in the home (phones, persons

coming in and out).• Maintain a comfortable temperature.• Ensure that the client is not hungry, in pain, or sleepy.• Have a family member present if desired or needed.• Use real equipment when possible to facilitate under-

standing. Have equipment that will be in the homedelivered prior to the teaching learning session toensure that the client is able to use the equipment.

• Keep the session short, factual, and to the point.• Use common vocabulary and avoid the use of medical

jargon.• Leave written materials in the home when possible.• Leave a phone number for the client to call should

further questions arise.

Provide referral as needed to include• Enterostomal therapist• Dietician• Physical therapy• Occupational therapy

Utilize adult teaching principles during educationalsessions:

• Focus on information that is important to the client.• Use teaching materials that appeal to many types of

learners (visual, auditory, kinesthetic).

Refer the client to community resources as appropriate:• Support groups for clients and families• Educational web resources

Client will not become discouraged by unrealistic goals.


Use of the interdisciplinary team facilitates most compre-hensive and accurate information and assistance for theclient.


Utilizing existing resources facilitates success and is timeand cost efficient.

*Impaired memory may be attributed to pathophysiologic or situationalcauses that are either temporary or permanent.


Memory, Impaired 483

••••••

EXPECTED OUTCOME

Will verbalize recall of [immediate information/recent infor-mation/remote information] by [date].

TARGET DATES

For some patients, this may be a permanent problem, sodates would be stated in terms of weeks and months. Forother patients, it would be appropriate to check for progresswithin 3 days.

5. Cerebral vascular accident6. Dementia


This diagnosis is very similar to other diagnoses inthis pattern; for example, Confusion and DisturbedThought Process. However, this diagnosis relatesspecifically to memory problems.


Adult Health


Identify self and the patient by name at each interaction.

Support and reinforce the patient’s efforts to rememberbits of information or behavioral skills.

Observe for improvement or deterioration in memorybased on the suspected or confirmed underlying med-ical diagnosis.

Teach the family about the patient’s condition and how torespond to the patient’s loss of memory.

Memory loss necessitates frequent orientation to person,time, and environment.

Reinforcing the patient’s efforts at remembering candecrease anxiety levels and perhaps help with furtherrecovery. Placing unrealistic expectations on the patientcan increase anxiety, frustration, and feelings of help-lessness.

Memory impairment due to some reversible physiologicproblem should improve as the condition becomesresolved. Memory impairment due to irreversiblephysiologic-physical problems generally will notimprove and will likely deteriorate over time.

Assists the family in understanding underlying cause(s)for memory impairment. Increases the family’s senseof competency in relating to the patient during periodsof memory loss

Child Health

Same as Adult Health within developmental capacity for infant or child, and safety-mindedness in all aspects.


Determine all who may need to be involved to best sup-port the infant or child in situations where actualknown level of involvement may not be clear.

Offer 30 minutes each shift and as needed for the parentsto express concerns.

Offer appropriate advocacy on behalf of the infant or childwhen the parents are unable to offer this component.

Ambiguous unknowns present frustration for all involved,so it is best to establish most complete team to managecare to foster holistic approach.

Reduces anxiety and offers insight into parental concerns.

Child advocacy will best protect the child’s interestswhen the parents cannot.

Women’s Health

Same as Adult Health except for magnesium sulfate therapy specific to pregnancy-induced hypertension. For midlifewomen, the actions and interventions are the same as those given for perimenopausal and menopausal life periods inDeficient Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern.




••••••


Mental Health


Monitor the client’s level of anxiety, and refer to Anxiety(Chapter 8) for detailed interventions related to thisdiagnosis.

Speak to the client in brief, clear sentences.

Interact with the client for [number] minutes every [num-ber] minutes. Begin with 5-minute interactions andgradually increase the length of interactions.

Be consistent in all interactions with the client.

Initially, place the client in an area with little stimulation.

Orient the client to the environment, and assign someoneto provide one-to-one interaction while the client ori-ents to unit.

Do not argue with the client about inaccurate memory ofsituations (e.g., the client insisting he or she has noteaten when he or she has just finished a meal). Informthe client in a matter-of-fact manner that this is notyour experience of the situation.

Provide orientation information to the client as needed.Specify here what information this client needs (e.g.,name on room, calendar, clock, written daily schedule,or information provided in written form in a notebookor on a white board).

Utilize reflection of the last statement made by the clientin conversations.

Establish a daily schedule for the client, and provide awritten copy to him or her or post a copy of the dailyschedule in an obvious location in the milieu. [Note theclient’s specific schedule here.]

Spend [number] minutes [number] times a day reviewingwith the client concerns about memory and developingmemory techniques. These could include visualimagery, mnemonic devices, memory games, associa-tion techniques, making lists, rehearsing information,or keeping a journal about activities.

Practice memory techniques with the client [number]minutes 2 times a day. [Note specific techniques to bepracticed.]

Spend [number] minutes following an activity discussingthe activity to provide the client with an opportunity topractice remembering.

Anxiety can increase the client’s confusion and disorgani-zation.

Too much information can increase the client’s confusionand disorganization, increasing memory problems.

Time of interaction should be guided by the client’s atten-tion span.

Facilitates the development of a trusting relationship, andmeets the client’s safety needs.

Inappropriate levels of sensory stimuli can contribute tothe client’s sense of disorganization and confusion,increasing memory problems.

Promotes the client’s safety needs while promoting thedevelopment of a trusting relationship.

Communicates acceptance of the client and promotesself-esteem.

Facilitates maintenance of self-esteem and memory.

Facilitates memory within conversation.

Decreases anxiety and promotes consistency.

Associating information from various senses enhancesmemory by providing meaningful links. Written mate-rial provides prompts.

Practice improves performance and integrates behaviorinto the client’s coping strategies.

Opportunities to use memory enhance memory.


Memory, Impaired 485

••••••


Provide positive verbal reinforcement to the client foraccomplishing task progress.

Sit with the client each morning and develop a list of theday’s activities. Review this list each evening.

Schedule the client for groups that provide opportunitiesto utilize memory. These could be current event groups,reminiscence groups, or life review groups. Note theclient’s group schedule(s) here, as well as the assistanceneeded from staff to get the client to the group(s).

Spend [number] minutes each week discussing theclient’s coping strategies with support system. Notehere person responsible and time for this discussion.

Positive feedback encourages behavior.

Provides practice with memory techniques.

Provides opportunities for the client to practice usingmemory, which enhances memory.

Support system reactions impact the client.

Gerontic Health


● N O T E : Aging clients may experience age related changes in memory to include for-getting specific details but remembering them later, ability to learn new information withsome difficulty in information retrieval, a general awareness of memory impairment, andmemory impairment that does not affect daily life.


Introduce self with each client contact.Use the client’s preferred name in course of conversations.Request photographs and names of significant others

from the family or caregiver.Maintain consistency in environment.Document any appliances client requires (prostheses, eye-

glasses, hearing aids, cane, or walker).Ensure permanent identification of all appliances required

by the client.Maintain consistent routine of care.Avoid arguments over forgetful behavior.

Omit statements or questions that emphasize memoryloss such as “Don’t you remember eating breakfast?”or “Do you know who came to see you this morning?”

In congregate social or living situations, introduce clientsprior to group activities.

Monitor solid and liquid intake on a daily basis.

Document responses to medications, and note anychanges in memory associated with medications.

Administer mental status examination on a semiannualbasis unless the client is receiving medication toenhance memory.

Monitor for changes in activities of daily living(ADLs) ability and for performance of ADLswithout prompting.

Promotes comfort for the client to identify caregiver.Provides orienting cue to the client’s identity.Provides information about the client and point of refer-

ence while providing care.Decreases need to cope with change on a frequent basis.Provides a record of needed equipment that the client

may not be able to recall.Assists in keeping equipment available to the client, and

eliminates potential of using incorrect assistive devices.Provides sense of the familiar.Promotes client self-esteem, and decreases potential for

escalating anxiety related to the memory loss.Promotes client self-esteem, and decreases potential for

escalating anxiety related to the memory loss.

Fosters social skills and interactions.

Memory loss may prevent the client from obtaining ade-quate nutrition or fluid intake.

Some medications may have side effects that in the olderclient promote amnesia. This problem can occur espe-cially with long-acting benzodiazepines and hypnotics.

Monitors memory function and may assist in identifyingchanging strengths. Increased frequency recommendedif the client is taking memory-improving medication.

If memory loss is progressive, ADL skills will decreaseover time and increased assistance will be needed.



PAIN, ACUTE AND CHRONIC

DEFINITIONS2

Acute Pain Unpleasant sensory and emotional experiencearising from actual or potential tissue damage, or describedin terms of such damage (International Association for theStudy of Pain). Sudden or slow onset of any intensity frommild to severe, with an anticipated or predictable end, and aduration of less than 6 months.

Chronic Pain Unpleasant sensory and emotionalexperience arising from actual or potential tissue damage,

or described in terms of such damage (InternationalAssociation for the Study of Pain). Sudden or slow onset ofany intensity from mild to severe, constant or recurring,without anticipated or predictable end and a duration oflonger than 6 months.


A. Acute Pain1. Verbal or coded report2. Observed evidence


••••••


Gerontic Health


Use distraction techniques if the memory-impairedclient becomes increasingly agitated or aggressivein the care setting.

Educate the caregiver to recognize signs of personalstress when caring for the client with impairedmemory.

Provide the caregiver information on available respiteservices.

Monitor the patient for changes in elimination patterns.

Distraction can allow time for the client to forget cause ofagitation.

Decreases potential for caregiver burnout.

Decreases potential for caregiver burnout.

The memory-impaired client may not be able to reportchanges in bowel or bladder function.

Home Health

● N O T E : If this is an acute development, immediate referral is required.


Assist the client and family in lifestyle adjustments thatmay be necessary:

• Provide a safe environment.• Structure teaching methods and interventions to the

person’s ability.• Explain to the family the changes from their usual roles

required in caring for the patient.

Assist the family to set criteria to help them determinewhen additional intervention is required (e.g., explainhow to recognize change in baseline behavior).

Refer to appropriate assistive resources as indicated.• Support groups for caregivers• Support groups for persons with similar problems• Home care assistance

Teach the client and family memory involvement tasks,such as reminiscence and memory practice exercises.

Teach the client and family compensation strategies (e.g.,daily planner or checklists).

Home-based care requires involvement of the family.Impaired memory can disrupt family schedules androle relationships. Adjustments in family activities androles may be required.


Additional assistance may be required for the family tocare for the person with impaired memory. Use ofreadily available resources is cost-effective.

Structured memory tasks can increase the client’s func-tional ability.

Compensation strategies can increase the client’s func-tional ability.


Pain, Acute and Chronic 487

••••••

3. Antalgic positioning to avoid pain4. Protective gestures5. Guarding behavior6. Facial mask7. Sleep disturbance (eyes lack luster, beaten look,

fixed or scattered movement, or grimace)8. Self-focus9. Narrowed focus (altered time perception, impaired

thought process, or reduced interaction with peopleand environment)

10. Distraction behavior (pacing, seeking out other peo-ple and/or activities, or repetitive activities)

11. Autonomic responses (diaphoresis; changes in bloodpressure, respiration, pulse; pupillary dilation)

12. Autonomic change in muscle tone (may span fromlistless to rigid)

13. Expressive behavior (restlessness, moaning, crying,vigilance, irritability, or sighing)

14. Changes in appetite and eatingB. Chronic Pain

1. Weight changes2. Verbal or coded report or observed evidence of pro-

tective behavior, guarding behavior, facial mask, irri-tability, self-focusing, restlessness, depression

3. Atrophy of involved muscle group4. Changes in sleep pattern5. Fatigue6. Fear of reinjury7. Reduced interaction with people8. Altered ability to continue previous activities9. Sympathetic-mediated responses (temperature, cold,

changes of body position, or hypersentivity)10. Anorexia

RELATED FACTORS2

A. Acute Pain1. Injury agents (biologic, chemical, physical, psycho-

logical)B. Chronic Pain

1. Chronic physical or psychosocial disability


1. Any surgical diagnosis2. Any condition labeled chronic, for example, rheumatoid

arthritis3. Any traumatic injury4. Any infection5. Anxiety or stress6. Fatigue


There are no other nursing diagnoses that areeasily confused with this diagnosis. Many of theother nursing diagnoses will serve as companiondiagnoses and may have pain as a contributingfactor to that diagnosis. For example, an individualwith chronic pain may be exhausted from trying todeal with the pain and have a companion diagnosisof Fatigue, or may be using alcohol or street drugsin an attempt to ease the pain and would have thecompanion diagnosis of Ineffective IndividualCoping.

EXPECTED OUTCOME

Will describe [number] of methods to facilitate pain controlby [date].

Will report a decrease in pain on a 0 to 10 scale by[date].

Will demonstrate the use of one nonanalgesic methodto prevent or control pain by [date].

TARGET DATES

Since uncontrolled pain affects a client’s ability to ambulateand heal properly, both short- and long-term goals for painmanagement are appropriate. Acute pain should be reducedwithin hours. Long term, pain should be managed so that apatient’s pain rating is at a level that is acceptable to them,generally less than 3 on a 0 to 10 scale.


Adult Health


Monitor for pain at least every 2 hours on [odd/even]hour. Utilize appropriate method of assessment (e.g.,numeric pain scales, behavior assessment).

Teach the patient to report pain as soon as it starts. Allowthe patient to describe the pain in detail to includeaggravating factors, relieving factors, type of pain(burning, tingling, throbbing).

Pain is subjective in nature, and only the patient can fullydescribe it.

Pain is more readily controlled when it is treated early.Treating pain at first report prevents the client fromexperiencing a “roller coaster” effect of pain reliefalternating with pain elevation.




••••••


Adult Health


Administer pain medication as prescribed. Reassess anddocument amount of pain relief within 30 minutes afteradministration. Devise alternate methods for pain reliefin conjunction with other health-care team members ifpain is not relieved. [Note that plan here.]

Consider continuous dosing (e.g., continuous drip or PCAfor patients with consistent pain).

Consider alternative methods including massage, biofeed-back, progressive relaxation, or guided imagery. [Notemethods to be used with client here.]

Turn at least every 2 hours on [odd/even] hour. Maintainanatomic alignment with pillows or other paddedsupport.

Provide calm, quiet environment.

Monitor vital signs at least every 4 hours while awake at[times].

Monitor the sleep–rest pattern. Promote rest periodsduring day and at least 8 hours sleep each night.(See nursing actions for Disturbed Sleep Pattern,Chapter 6.)

Check bowel elimination at least once per shift.

Allow time for the patient to discuss fears and anxietiesrelated to pain by scheduling at least 15 minutes onceper shift to visit with the patient on one-to-one basis.

Collaborate with health-care team regarding use of tran-scutaneous electrical nerve stimulation (TENS).

Teach the patient and significant others:• Cause of pain• Common and expected side effects of analgesics• The low rate of addiction when narcotics are used

for pain• The importance of maintaining round-the-clock

dosing for continuous pain and preventive dosingfor expected pain

• Avoiding and minimizing pain• Splinting• Gradual increase in activities• Use of alternative noninvasive techniques (See previous

nursing action.)• Combining techniques (e.g., medication with relaxation

technique)

Refer the patient to or collaborate with other health-careprofessionals.

Response to pain and pain medication is unique to eachpatient.

Avoids a roller coaster effect in pain relief.

Helps stimulate circulation. Alignment helps prevent painfrom malposition and enhances comfort.

Promotes action and effect of medication by providingdecreased stimuli.

Detects early changes that might indicate pain.

Fatigue may contribute to an increased pain response, orpain can contribute to interrupted sleep.

Immobility caused by pain may decrease the parasympa-thetic stimulation to the bowel. Many analgesics haveconstipation as a side effect.

Just as pain is unique to the individual, so is the pain con-trol intervention. Discussions with the patient providecollaboration and increase the patient’s compliance.Decreases feeling of powerlessness, and initiates basicteaching regarding control of pain.

Collaboration promotes the best approach to pain man-agement.

Knowledge assists the patient in feeling like an activeparticipant on the health team. Decreases sense ofpowerlessness. Promotes effective pain management.

Collaboration promotes the best long-range plan for man-agement of pain.



Keep current on comparative doses of analgesics, true effectof so-called potentiators, and noninvasive means of painrelief. Do not worry about a patient becoming addicted.With the average length of stay of 3 to 5 days, it is doubtfuladdiction could occur. Current research in this area shows an

extremely low rate of addiction due to medication adminis-tration in a health-care setting. The same research indicatesthat we undermedicate, rather than overmedicate, for pain.Undermedication is particularly true in the case of infants,children, and older adults. See the Department of Healthand Human Services Guidelines60 for a discussion of thisresearch as well as further information on pain control.


••••••

Child Health


Monitor for contributory factors to pain at least every 1 to2 hours, or according to need.

• Physical injury or surgical incision• Stressors• Fears• Knowledge deficit• Anxieties• Fatigue• Description of exact nature of pain, whether per the

McGill, Elkind or faces by Wong pain assessment tool• Vital signs—many consider pain to be a fifth vital sign.• Response to medication• Meaning of pain to the child and family

Provide appropriate support in management of pain forthe patient and significant others by:

• Validation of the pain• Maintaining self-control to extent feasible• Providing education to deal with pain and assist the

patient and family to talk about the pain experience byallowing at least [number] minutes per shift for suchventilation and education at [times]. [Note topics to beaddressed for this client here.]

• Allowing the parents to be present and participate incomforting of the patient; assisting the child and par-ents to develop a plan of care that addresses individualneeds and is likely to result in a better coping pattern(particularly for chronic pain). [Note client’s planhere.]

• Appropriate diversional activities for age and develop-mental level

*Collaborate with child life specialist to identify appro-priate activities.

• Attention to controlling external stimuli such as noiseand light

• Use of relaxation techniques appropriate for the child’scapacity. (This could include visual imagery of favoriteplaces or comforting situations.)

• Appropriate follow-up of pain tolerance and responseto medication as ordered.

Facilitate provision of pain medication by least invasiveand most effective. Insist on appropriate and promptmode for relief of pain.

Provides the essential database for planning and modifi-cation of planning.

Validation and support of the patient and family willserve to show value and respect for the individual’shealth need. Maintains basic standards of care.Ventilation reduces anxiety, and parental involvementenhances coping skills.

Utilize least invasive and most individually safe, effectiveand appropriate mode of pain relief for child.




••••••


Child Health


If IV route is utilized, monitor for respiratory and bloodpressure depression every 10 minutes � 6 at [times].

Monitor intake and output for decrease as a result ofhypomotility or spasm.

Give appropriate emotional support during painful proce-dures or experiences:

• Provide explanations at the child’s level of opennessand honesty.

• Use puppets to demonstrate the procedure.• Explain to the parents that even if the child cries exces-

sively, their presence is encouraged.• Comfort child before, during, and after procedure.• Reward the child for positive behavior according to

developmental need (e.g., stars on a chart). [Noterewards to be used here.]

• Facilitate parents and child sharing feelings about thepainful experience while providing care.

Collaborate with or refer the patient to appropriatehealth-care team members.

Teach the patient and family ways to follow up at homeor school with needed pain regimen:

• Appropriate timing of medication• Appropriate administration of medication• Not to substitute acetaminophen for aspirin in arthritis• Contact the school nurse with the plan of care

Monitor for side effects of medications such as decreasedperistalsis, GI bleed, and respiratory depression.

Develop daily plans for pain management that meet thechild’s individual needs. [Note that plan here.]

Develop several contingency pain control plans. Noteplans for this client here.

● N O T E : Chronic pain is going to recur; therefore, there is a need for long-termfollow-up. This follow-up is especially critical because chronic pain places the patientat risk for developmental delays and altered quality of life.

Women’s Health

Gynecologic Pain

● N O T E : A significant amount of the pain experienced by women is associated with thepelvic area and the reproductive organs. Determining the origin of the pain is one of themost difficult tasks facing nurses dealing with the gynecologic patient. An organic expla-nation for pain is never found in approximately 25 percent of women. Because of theclose association with the reproductive organs, gynecologic pain can be extremelyfrightening, can connote social stigma, affect the perception of the feminine role, causeanger and guilt, and totally dominate the woman’s existence. “Pain is culturally moreacceptable in certain parts of the body and may elicit more sympathy than pain in othersites.”31,62



••••••


Identify factors in the patient’s lifestyle that could becontributing to pain.

Record accurate menstrual cycle and obstetric, gyneco-logic, and sexual history, being certain to note prob-lems, previous pregnancies, descriptions of previouslabors, previous infections or gynecologic problems,and any infections as a result of sexual activities.

Assist the client to describe her perception of pain as itrelates to her.

Include dysmenorrhea pain pattern, being certain to deter-mine whether the pain occurs before, during, or aftermenstruation.

Monitor disturbance of the client’s daily routine as aresult of pain. Have the patient describe the location ofthe pain (e.g., lower abdomen, legs, breast, or back).

Have the patient describe any edema, especially “bloat-ing” at specific times during the month.

Have the patient describe the onset and character of thepain (e.g., mild or severe cramping).

Ascertain whether the pain is associated with nausea,vomiting, or diarrhea.

Identify any precipitating factors associated with pain(e.g., emotional upsets, exercise, or medication).

Assist the patient in identifying various methods of painrelief, including exercise (pelvic rock), biofeedback,relaxation, and medication (analgesics andantiprostaglandins).

Provides the database to adequately assess pain and deter-mine the underlying cause.

This information can assist in pinpointing source of painand devising a plan of care.

Individualizes pain control and provides options for thepatient.

Women’s Health

Labor Pain and Nursing


LaborEncourage the patient to describe her perception of labor

pain related to her previous laboring experiences.

Provide factual information about the laboring process.

Refer the patient to childbirth preparation group (e.g.,Lamaze groups).

Describe methods of coping with labor pain (e.g., relax-ation, imaging, breathing, medication, hydrotherapy, orambulation).

Provide support during labor.

Encourage involvement of significant others as supportduring labor process.

PostpartumEncourage the patient to describe her perception of pain

associated with the postpartum period.

Providing information about the laboring process helpsthe patient cope with the pain of labor.13,31,63




••••••


Women’s Health


Provide information for pain relief (e.g., Kegel exercises,sitz baths, or medications).

Explain etiology of “afterbirth pains” to involution ofuterus.

Explain the relationship of breastfeeding to involutionand uterine contractions.

Assist the patient in putting on a supportive bra.

Encourage early, frequent breastfeedings to enhance let-down reflex.

Support the patient and provide information on correctbreastfeeding techniques, such as changing positionsfrom one feeding to next to distribute sucking pressureand prevent sore nipples.

Check the baby’s position on the breast; be certain theareola is in mouth and not just the nipple.

Provide warm, moist heat for relief of engorged breasts.

Provide analgesics for discomfort of engorged breasts.

Pump after the infant nurses until the breast is emptied.

Encourage the patient to nurse on least sore side first toencourage let-down reflex.

Apply ice to nipple just before nursing to decrease pain.

Knowing the source of pain increases the patient’s senseof control.

Knowledge of how to lessen discomfort during breast-feeding contributes to successful or effective breast-feeding.

Demonstrates to the patient various pain relief methods.

Mental Health

● N O T E : Pain in the mental health client should be carefully assessed for physiologiccauses. The following interventions are for pain associated with psychological factors orchronic pain. For chronic pain, they are used in conjunction with physiologic interven-tions. Refer to Adult Health nursing actions for physiologic pain management strategies.


Monitor the nurse’s response to the client’s perception ofpain. If the nurse has difficulty understanding or cop-ing with the client’s expression of pain, he or sheshould discuss these feelings with a colleague in anattempt to resolve the concerns.

Note any recurring patterns in the pain experience, suchas time of day, recent social interactions, or physicalactivity. If a pattern is present, begin a discussion ofthis observation with the client.

Determine effects pain has had on the client’s life, includ-ing role responsibilities, financial impact, cognitive andemotional functioning, and family interactions.

Review the client’s beliefs and attitudes about the rolepain is assuming in the client’s life. If pain is veryimportant to the client’s definition of self, assure theclient that you are not requiring him or her to give up

The nurse’s response to the client can be communicatedand have an effect on the client’s level of anxiety,which can then affect the pain response.

Initiates the client’s awareness of this pattern, and allowsthe nurse to assess the client’s perception of this obser-vation.

Assesses meaning of pain to the client’s amount of anxi-ety associated with the pain and possible benefits ofpain in the client’s life. Change depends on the client’sperception of the problem.58

If pain is assuming an important role, then it might bedifficult for the client to “give up” all of the pain, andthis should be considered in all further interven-tions.49,50



••••••


the pain by indicating that you are only interested inthat pain that causes undue discomfort or by indicatingthat this client’s pain is special and that it would be dif-ficult, if not impossible, for the health care team to getrid of it.

Spend brief, goal-directed time with the client when he orshe is focusing conversation on pain or pain-relatedactivities.

Schedule a time with the client when he or she is notcomplaining about pain. List this schedule here. Focuson special activities in which the client is involved orfollow-up on a non–pain-related conversation the clientseemed to enjoy.

Find at least one non–pain-related activity the clientenjoys that can be the source of positive interactionbetween the client and others, and encourage clientparticipation in this activity with positive reinforce-ment (list client-specific positive reinforcers here alongwith the activity).

Discuss with the client alternatives for meeting personalneed currently being met by pain. You may need torefer the client to another, more specialized careprovider if this is a problem of long standing or if theclient demonstrates difficulty in discussing these con-cerns. Refer to the self-esteem diagnoses (Chapter 8)for specific interventions related to perceptions of self.

Develop with the client a plan to alter those factors thatintensify the pain experience. For example, if the painincreases at 4 P.M. each day and the client associatesthis with his boss’s daily visit at 5 P.M., then the planmight include limiting the visits from the boss or hav-ing another person present when the boss visits. [Listspecific interventions here.]

Develop with the client plan for learning relaxation tech-niques, and have the client practice technique 30 min-utes two times a day at [times]. Remain with the clientduring practice session to provide verbal cues andencouragement as necessary. These techniques caninclude:

• Meditation• Progressive deep muscle relaxation• Visualization techniques that require the client to visu-

alize scenes that enhance the relaxation response (suchas being on the beach or having the sun warm thebody)

• Biofeedback• Prayer• Autogenic training

Monitor interaction of analgesic with other medicationsthe client is receiving, especially antianxiety, antipsy-chotic, and hypnotic drugs. Collaborate with pharma-cist and physician to maintain adequate pain control.

Decreases positive reinforcement for the client’s focus onpain and diminishes secondary gain for pain.

Provides positive feedback to the client about an aspectof himself or herself that is not pain related.

Reinforcement encourages a positive behavior andimproves self-esteem.

The social milieu can change the basic quality of the painexperience.

These techniques decrease anxiety.

These medications may potentiate one another.




••••••


Mental Health


Review the client’s history for indication of illicit druguse and the effects this may have on the client’s toler-ance to analgesics.

If the client is to be withdrawn from the analgesic, dis-cuss the alternative coping methods and how they willassist the client with the process. Assure the client thatsupport will be provided during this process. Help theclient identify those situations that will be most diffi-cult, and schedule one-to-one time with the client dur-ing these times.

• Develop plan with client for management of pain with-out analgesics. [Note patients plan here.]

If the client demonstrates altered mood, refer to Ineffec-tive Individual Coping (Chapter 11) for interventions.

Consult with occupational therapy to assist the client indeveloping diversional activities. [Note time for theseactivities here as well as a list of special equipmentthat may be necessary for the activity.]

Consult with physical therapy to develop exercise rou-tines that will facilitate pain management. [Note sup-port needed from nursing to facilitate exercise plan.]

Involve the client in group activities by sitting with himor her during a group activity, such as a game, orassign the client a responsibility for preparing one partof a unit meal. Begin with activities that require littleconcentration, and then gradually increase the taskcomplexity.

Consult with physician for possible referral for use ofhypnosis in pain management.

Sit with the client and the family during at least two visitsto assess family interactions with the client and therole pain plays in family interaction.

Discuss with the client the role of distraction in painmanagement, and develop a list of those activities theclient finds distracting and enjoyable. These couldinclude listening to music, watching television or spe-cial movies, or physical activity. Develop with theclient a plan for including these activities in the painmanagement program, and list that plan here.

Discuss with the client the role that exercise can play inpain management, and develop an exercise programwith the client. This should begin at or below theclient’s capabilities and could include a 15-minutewalk twice a day or 10 minutes on a stationary bicycle.[Note the plan here, with the type of activity, length oftime, and time of day it is to be implemented.]

Provide positive reinforcement to the client for imple-menting the exercise program by spending time with

The client may have developed a cross-tolerance for thesedrugs.

Promotes perception of control, and decreases anxiety.

Decreases conscious awareness of pain, thus decreasingthe pain experience.

Alters the client’s perception of the pain.

Provides other pain relief options for the client.

Exercise encourages release of natural endorphins.

Positive reinforcement encourages repeating the behaviorand enhances self-esteem.



••••••


the client during the exercise, providing verbal feed-back, and allowing the client the rewards that havebeen developed. These rewards are developed with theclient. [Note reward schedule to be used here.]

Monitor family and support system understanding of thepain and perceptions of the client. If they demonstratethe attitude that interaction with the client is closelylinked with the pain, then develop a plan to includethem in the experiences described here. List that planhere. Consider referral to a clinical specialist in mentalhealth nursing or a family therapist to assist the familyin developing non–pain-related interaction patterns.

Provide ongoing feedback to the client or support systemabout progress.

Refer to outpatient support systems, and assist witharranging for the client to contact these systems beforedischarge.

Assists the family in normalizing and in moving awayfrom a pain-focused identity.

Long-term support enhances the likelihood of effectivehome management.

Gerontic Health



Acute PainAsk the client about the presence of pain using a 0 to 10

scale, word descriptor scale, faces scale, or pain ther-mometer at least every 2 hours.

For clients with cognitive impairment, assessment ofbehaviors and family or caregiver observations shouldbe used to assess for pain.

Abstain from the use of placebos.

Opioids for episodic pain (non-recurring) should be pre-scribed as needed, rather than round the clock. (NGC,Retrieved February 8, 2006 from http:// www.guide-lines.gov)

Assess the client often and regularly for breakthroughpain:

• End of dose failure• Incident pain• Spontaneous, unpredictable pain and titrate dose

accordingly

Titrate medications in the older client carefully, consider-ing the propensity for drug accumulation, drug interac-tions, and side effects.64

Assess clients taking opioid analgesics regularly andoften for alterations in bowel function and treat consti-pation as needed. Anticipate slowed bowel motilitywhen starting an opioid analgesic and begin preventivestool softeners concurrently.64

Pain is often underreported or minimized. Asking andusing a scale facilitates reporting and understanding ofpain intensity.

Early identification of pain facilitates effective treat-ment.64

The use of placebos is unethical and impairs the trustrelationship between client and nurse.64

Prevention of overuse.

Maintain adequate pain control.

Pharmocokinetics and pharmacodynamics are affected bythe aging process.

Opioid analgesics consistently cause slowing in bowelmotility and subsequent constipation.




••••••


Gerontic Health


Medicate every 4 to 6 hours rather than on an as needed(PRN) basis for the first 48 to 72 hours, especiallypostoperatively.65

Collaborate with physician to prescribe medications otherthan meperidine, talwin, methadone, and darvon, if anarcotic analgesic is required.

When beginning a new medication for pain, start with thelowest dose and increase slowly as needed.66

Investigate the patient’s beliefs regarding pain. Does heor she consider pain a punishment? Does he or shethink that having to take pain medication signals severeillness or a potential for dying?67

Teach the patient to report pain as soon as it occurs, espe-cially if medication order is PRN.

Avoid presenting self in a hurried manner.

Chronic PainExplore with the patient how he or she has managed

chronic pain in the past.

Determine use of distraction in helping the patient copewith chronic pain.65

Monitor skin status when thermal interventions are used,such as ice or heat packs.

In the presence of chronic pain, depression may alsoexist. Screen for depression.64

Enhances pain control, and thus promotes early mobility,which decreases the potential for postoperative compli-cations.

These medications are more likely to cause side effectssuch as confusion and psychotic behavior when givento the older adult.66

Older adults often respond differently to pain medicationsthan younger adults.

May be a barrier to seeking pain relief.

Pain is more easily controlled when treated early. Patientmay not realize that medication won’t be given on ascheduled basis.

Older adults are less likely to report pain if caregiver isrushed.67

Assists in determining what measures were of significantor of little help.

Music, humor, and relaxation techniques can providetemporary respite from discomfort.

Changes in sensation may result in thermal injury if notclosely monitored.

Chronic pain is exhausting physically and mentally.

Home Health


Teach the client and family measures to promote comfort:• Proper positioning• Appropriate use of medications (e.g., narcotics as

ordered, nonnarcotic analgesics, anti-inflammatories)• Knowledge regarding source of pain or of disease

process• Self-management of pain and of care as much as is

appropriate• Relaxation techniques• Therapeutic touch• Massage (if not contraindicated)• Distraction• Breathing techniques• Heat or cold treatments (if not contraindicated)• Regular activity and exercise• Planning and goal setting

Involvement of the client and family promotes comfortand decreases self-reported pain and analgesic use.65


Sensory Perception, Disturbed (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) 497

••••••


• Biofeedback• Yoga or tai chi• Imagery or hypnosis• Group or family therapy

Teach the client and family factors that decrease toleranceto pain and methods for decreasing these factors:

• Lack of knowledge regarding disease process or paincontrol methods

• Lack of support from significant others regarding theseverity of the pain

• Fear of addiction or fear of loss of control.• Fatigue• Boredom• Improper positioning

Involve the client and family in planning, implementing,and promoting reduction in pain:

• Family conference• Mutual goal setting• Communication• Support for the caregiver


• Occupational changes• Family role alterations• Comfort measures for chronic pain• Financial situation• Responses to pain (mood, concentration, or ability to

complete activities of daily living)• Coping with disability or dependency• Mechanism for altering need for assistance• Providing appropriate balance of dependence and inde-

pendence• Stress management• Time management• Obtaining and using assistive equipment (e.g., for

arthritis)• Regular, rather than as-needed, schedule of pain med-

icationTeach the client and family purposes, side effects, and

proper administration techniques of medications.Consult with or refer to appropriate assistive resources as

indicated.

Reducing these factors can increase the tolerance topain.66

Addiction occurs very infrequently in clients medicatedfor legitimate pain.64

Involvement improves motivation and improves outcome.

Lifestyle changes require changes in behavior.

Provides necessary information for safe self-care.

Use of the existing community services network provideseffective utilization of resources.

SENSORY PERCEPTION, DISTURBED(SPECIFY: VISUAL, AUDITORY,KINESTHETIC, GUSTATORY,TACTILE, OLFACTORY)

DEFINITION2

Change in the amount or patterning of incoming stimuliaccompanied by a diminished, exaggerated, distorted, orimpaired response to such stimuli.2


1. Poor concentration2. Auditory distractions3. Change in usual response to stimuli4. Restlessness5. Reported or measured change in sensory acuity6. Irritability7. Disoriented in time, in place, or with people8. Change in problem-solving abilities


9. Change in behavior pattern10. Altered communication patterns11. Hallucinations12. Visual distortions

RELATED FACTORS2

1. Altered sensory perception2. Excessive environmental stimuli3. Psychological stress4. Altered sensory reception, transmissions, and/or integra-

tion5. Insufficient environmental stimuli6. Biochemical imbalances for sensory distortion (e.g., illu-

sions or hallucinations)7. Electrolyte imbalance8. Biochemical imbalance


1. Any neurologic diagnosis2. Glaucoma or cataracts3. Intensive care unit patient4. Psychosis5. Substance abuse6. Toxemia


Disturbed Thought ProcessDisturbed Thought Process refers to a patient’s cogni-tive abilities, whereas Disturbed Sensory Perceptionrelates to just the sensory input–output.

Self-Care DeficitCertainly sensory perception problems could result inself-care deficits; however, one diagnosis refers toability to care for the self, whereas the other focuseson response to sensory input.

EXPECTED OUTCOME

Will identify and initiate at least two adaptive ways to com-pensate for [specific sensory deficit] by [date].

TARGET DATES

Assisting the patient in dealing with an uncompensated sen-sory deficit is a long-term process. Also, the patient maynever accept the deficit but can be helped to adapt to thedeficit. Therefore, an appropriate target date would be nosooner than 5 to 7 days from the date of diagnosis.


••••••


Adult Health


Check safety factors frequently:• Siderails• Uncluttered room• Lighting: Dim at night, increased during day, and

nonglare• Environment arranged to assist in compensating for

specific deficit• Orient to room• Provide calm, nonthreatening environment

Place bedside table and over-the-bed table in same posi-tion each time and within easy reach. Ascertain whichitems the patient wants on these tables and where theitems are to be placed. Place items in same place eachtime.

Have significant others bring familiar items from home.

Promote consistency in care (e.g., same nurse, as nearsame routine as possible).

Follow the patient’s own routine as much as possible (e.g.,bath, bedtime, meals, and grooming. Pace activities tothe patient’s preference). [Note client preferences here.]

Provide reality orientation as necessary:


Maintains consistency of environment, which facilitatesthe patient’s comfort and decreases anxiety.

Enhances physical and psychological comfort.

Decreases unessential stimuli. Inspires trust. Reinforcesthe patient’s own routine.

Promotes comfort and empowers the patient.

Reinforces reality.



••••••


• Keep clock and calendar in room.• Touch the patient frequently.• Check orientation to person, time, and place at least

once per shift.• Listen carefully.

Collaborate with occupational therapist regarding appro-priate diversionary activity. [Note recommendationshere with support needed for implementation.]

Auditory DeficitEnhance communication by speaking in low tones when

interacting with the patient.• Do not shout when talking with the client.

• Decrease background noise as much as possible whentalking with the client.

• Stand where the client can watch your lips when youare speaking to him or her.

Allow the patient extended time to respond to verbalmessages.

Use visual cues as much as possible to enhance verbalmessages.

• Provide message board to use with the patient.

Teach the patient and family proper maintenance of hear-ing aid.

• Replace batteries in hearing aids and clean earwax forear mold of hearing aid as necessary

Visual DeficitAssure that glasses or other visual aids are available and

placed proximal to patient.

Provide written information in large-print or audiorecorded format.

Provide telephone dials and other equipment necessarythat have large numbers on nonglare surfaces. List herespecial equipment that is necessary for this patient andwhen the patient may need it so it can be provided atappropriate times.

Identify the patient’s room with large numbers or thepatient’s name in large print.

Provide large-screen television and pictures with large,colorful images.

Provide nonglare work surfaces.

Identify stairs and door frames with contrasting tape orpaint.

Verbally address the patient when entering the patient’sproximity, and approach the patient from the front.

Do not alter the patient’s physical environment withouttelling him or her of the changes.

Teach the patient and family proper maintenance of eye-glasses and other prosthesis.

Provides stimuli.

Allows for alteration in hearing high-frequency sounds.High-frequency tones are lost first.

Shouting accentuates vowel sounds while decreasing con-sonant sounds.

Avoids confusion, and increases the patient’s ability tolocalize sounds.

Allows for understanding and interpretation of message.

Utilizes alternative communication methods.

Promotes proper functioning of hearing aid.

Facilitates the patient’s use of equipment, and assists inpreventing damage or loss of equipment.

Larger images are easier for the patient to interpret.

Increases visual acuity. Basic safety measure.

Makes the patient aware of presence.

Promotes consistency in environment, which improvessafety.

Ensures proper functioning and prevents scratching oflenses.




••••••


Adult Health


Teach the patient and family methods to improve environ-mental safety.

Assist the patient with activities of daily living (ADLs) asnecessary. List the activities that require assistancehere, along with the type of assistance that is needed(e.g., assisting the patient to eat to extent necessary[feed totally or cut up food and open packages]).

Touch and Kinesthesia DeficitProvide safe environment:• Remove sharp objects from the patient’s environment.• Protect the patient from exposure to excessive heat and

cold.

Teach patient to utilize visualization as a method toassess for injury and method for compensation fordecrease in tactile response.

Have the patient change position every 2 hours on[even/odd] hour.

Monitor condition of skin every 4 hours at [times]. Noteany alteration in integrity. Teach the patient to visuallyinspect skin on a daily basis.

Assist the patient in determining whether clothing is fit-ting properly without abrading the skin.

Perform and teach adequate foot care on a daily basis toinclude: [Note schedule here and teaching plan.]

• Bathing feet in warm water• Applying moisturizing lotion• Trimming nails as needed• Checking skin for abrasions or reddened areas

Assist the patient with care of affected body parts.

Assist the patient with ADLs (note type and amount ofassistance needed here).

Refer the patient to occupational therapy for assistingwith learning new self-care behavior.

Olfactory DeficitTeach patient to utilize other senses to adapt to deficit

including visualization, color and texture assessments.

Determine effect the smell deficit has on the patient’sappetite, and work with dietitian to make meals visu-ally appealing.

Provide for appropriate follow-up appointments beforedismissal. [Note referral plan here.]

Allows the patient to be as independent as possible.


Basic safety measures to prevent accidental burns.

Promotes circulation, and relieves pressure on bonyprominences.

Guards against skin breakdown.

Prevents unilateral neglect, and provides cues for thepatient.

Promotes self-care through demonstrating care to thepatient.

Assists to compensate for loss of smell.

Providing specific appointments lessens the confusionabout the specifics of appointments and increases thelikelihood of subsequent follow-through.



••••••

Child Health


Determine how the parent and child perceive the deficitaddressed by setting aside adequate time (30 minutes)each shift for discussion and listening.

Facilitate follow-up evaluation for any suspected sensorydeficits of infants and young children. [Note plan forfollow-up here.]

Provide safe environment according to sensory deficit andthe child’s developmental capacity. [Note special adap-tations for client here.]

Initiate plans for discharge immediately to provide timefor building confidence in the performance of necessaryself-care tasks.

Provide attention to family coping as it may relate to thedeficit:

• Monitoring of usual dynamics• Identification of impact on the parents and siblings• Presence of mental deficits• Values regarding the deficit• Support systems

Review for appropriate immunization, especially rubella,mumps, and measles.

In the presence of ear infections, exercise caution regard-ing use of ototoxic medications.

Correlate medical history for potential risk factors such aschronic middle ear infections, upper respiratory infec-tions, or allergies.

Provide appropriate sensory stimulation for age, begin-ning slowly so as not to overload child. [Note specialadaptations for this client here.]

Deal with other contributory factors such as nutrition,illness, or effects from behavioral disorders ormedications.

Include the parents in plans for rehabilitation wheneverpossible by:

• Using basic plan for care• Adapting intervention as required for the child• Supporting them in their role• Pointing out opportune times for interaction• Informing them of appropriate safety precautions for

the child’s age and situation• Encouraging gentle handling and comforting of the

infant

Provide continuity in staffing for nursing care of the childand family.

Appropriate attention to both subjective as well as objec-tive data is required to best plan care.

Preventing or minimizing secondary and tertiary deficitsis enhanced by appropriate attention to sensory percep-tion follow-up.

Sensory deficits and developmental capacity increase therisk of accidents.

Adequate practice time in a nonjudgmental situationallows positive feedback and corrective action. Lessensanxiety and performance pressures. Increases confi-dence in giving care at home.

A child with sensory perception problems and the inter-ventions necessary to deal with these problems placestrain on the family. Promoting coping will lessen thestrain on the family while increasing the likelihood thatthe child’s needs are met.

In the event of early deficits, the likelihood exists for theneed to modify the schedule of immunization. This istoo often overlooked and will then place the infant orchild at unnecessary risk for infectious diseases.

Treatment for chronic infections with antibiotics by sev-eral practitioners must be carried out with precautionto prevent potential side effects.

Contributory factors to the pattern of health must be pur-sued with openness to all possible causes.

Appropriate sensory stimulation will favor gradualprogress in development.

Related factors must be considered in total health of theinfant or child with altered sensory–perceptual pattern.

Inclusion of the parents provides an opportunity for learn-ing essential skills and enhances security of the infantor child. All efforts contribute to empowerment andpotential growth of the family unit.

Continuity provides trust and opportunities for reinforce-ment of learning.




••••••


Child Health


In instances of a handicapped child, provide appropriateattention to developing sequencing to best actualizepotential offered.

Especially note, on follow-up, the home environment fornurturing aspects and support systems.

Appropriate introduction of new skills or reinforcementof existent patterns will favor progress.

The home to which the infant or child will go may requirereasonable adaptation to foster appropriate resources.

Women’s Health


VisionMonitor the patient for signs of pregnancy-induced

hypertension (PIH).Monitor for signs and symptoms of preeclampsia (e.g.,

headaches, visual changes such as blurred vision,increased edema of face, oliguria, hyperreflexia, nauseaor vomiting, and epigastric pain).13,14

Teach the patient the importance of reporting these signsand symptoms, because they can be precursors toeclampsia.

SmellBe aware of the patient’s tendency during early preg-

nancy to experience morning sickness, i.e., nausea andvomiting.

In collaboration with dietitian:• Obtain dietary history.• Assist the patient in planning diet that will provide ade-

quate nutrition for her and her fetus’s needs.Teach methods for coping with gastric upset, nausea, and

vomiting:• Eating bland, low-fat foods• Increasing carbohydrate intake• Eating small, frequent meals• Having dry crackers or toast before getting out of bed• Taking vitamins and iron with snack before going to

bed• Supplementing diet with high-protein liquids (e.g.,

soups or eggnog)

Touch During PregnancyBe aware of the expectant mother’s sensitivity to extrane-

ous touching:• Shyness• Protectiveness of unborn child• Uterine sensitivity during pregnancy and particularly

during labor

Maternal TouchEncourage visual and tactile contact between the mother

and infant as soon as possible.

Knowledge of signs of visual disturbances associated withPIH can assist the patient in seeking early treatment.13,14

Knowledge can assist the patient in planning actions todecrease incidences of nausea and vomiting and assistin preventing dehydration and possibly hospitalization.

Assists the mother to know that her feelings are normal.

Provides time for beginning attachment process betweenthe mother and infant.



••••••

Mental Health


Monitor the client’s neurologic status as indicated by cur-rent condition and history of deficit (e.g., if deficit isrecent, assessment would be conducted on a schedulethat could range from every 15 minutes to every 8hours). Note the frequency and times of checks here. Ifchecks are to be very frequent, then it might be usefulto keep a record of these checks on a flow sheet.

If deficit is determined to result from a psychologicalrather than a physiologic dysfunction, refer toIneffective Individual Coping, Disturbed Body Image,Anxiety, and Chronic Low or Situational Low Self-Esteem for detailed nursing actions.

Client safety is of primary importance. Early recognitionand intervention can prevent serious alterations.

Client safety is of primary importance.


Provide an atmosphere conducive to continualmother–infant contact.

Delay newborn eye treatment for 1 hour, so that the babycan see the mother’s face.

KinesthesiaBe aware of the expectant mother’s increased vulnerabil-

ity related to physical size of body in third trimester:• Protectiveness of unborn child• Heavy movement• Possible slowed reflexes• Tires easily

Assist in and out of furniture that is too low and difficultto get up from.

Encourage correct body mechanics when lying down orsitting up.

Encourage to wear seat belt when traveling in automo-bile. (Shoulder belts are best.)

Reassures mothers that this is a temporary state.

Provides for safety measures for the mother and fetus.

● N O T E : A comprehensive physical examination and other diagnostic evaluationsshould be completed before this determination is made. Each of these deficits can besymptoms of severe physiologic or neurologic dysfunction and should be approachedwith this understanding, especially in a mental health environment where the clientsmay be assigned without careful assessment. This is a great risk for the client who hasa history of mental health problems.

If deficit is related to a physiologic dysfunction, attend toneeds resulting from the identified sensory deficit in amatter-of-fact manner, providing basic care and havingthe client do the majority of the care. (See AdultHealth interventions for additional care.)

If deficit is related to a psychological dysfunction, spend[number] minutes every hour with the client in anactivity that is not related to the sensory deficit. Ifthe client begins to focus on the deficit, terminate theinteraction.

Provides positive reinforcement for adaptive copingbehaviors.

Promotes the client’s sense of control, and increases self-esteem. Provides positive reinforcement for positivecoping behaviors and removes social reinforcement fornegative coping behaviors.19




••••••


Mental Health


Spend [number] minutes twice a day discussing with theclient the effects the deficit will have on his or her lifeand developing alternative coping behavior. Note timesfor conversations here. If the family is involved in theclient’s care, they should be included on a plannednumber of these interactions.

Refer to appropriate mental health professional if theclient is going to require long-term assistance in adapt-ing to the deficit or if current emotional adaptationbecomes complicated.

Discuss with the client and support system the necessaryalterations that may be necessary in the home environ-ment to facilitate daily living activities.

Auditory or Visual Alterations68–71

Observe for signs of hallucinations (intent listening for noapparent reason, talking to someone when no one ispresent, muttering to self, stopping in mid-sentence, orunusual posturing). When these symptoms are noted,engage the client in here-and-now, reality-oriented con-versation or involve the client in here-and-now activity.

Initiate touch only after warning the client that you aregoing to touch him or her.

Communicate acceptance to the client to encourage thesharing of the content of the hallucination.

If hallucinations place the client at risk for self-harm orharm to others, place the client on one-to-one observa-tion or in seclusion.

If the client is placed in seclusion, interact with the clientat least every 15 minutes.

Have the client tell staff when hallucinations are presentor when they are interfering with the client’s ability tointeract with others.

Maintain environment in a manner that does not enhancehallucinations (e.g., television programs that validatethe client’s hallucinations, abstract art on the walls,wallpaper with abstract designs, or designs thatenhance imagination).

Teach the client to control hallucinations by:• Checking ideas out with trusted others• Practicing thought stopping by singing to self, telling

the voices to go away (This can be done quietly to self,or by asking the voices to come back later, but not totalk now.)

• Telling the voices to go away, using headphones tolisten to music, watching TV, or wearing ear plug inone ear.


Interrupts patterns of hallucinations.

The client may perceive touch as a threat and respond inan aggressive manner.

Provides information on the content of the hallucinationso early intervention can be initiated when content sug-gests harm to the client or others.

Client and staff safety are of primary importance.

Provides reality orientation, and assists the client in con-trolling the hallucinations.

Early intervention promotes the client’s sense of safetyand control.

High levels of environmental stimuli can increase theclient’s disorganization and confusion.

Promotes the client’s sense of control, and enhances self-esteem. Provides control of auditory alterations.72



••••••


When the client is not constantly experiencing alterations,engage him or her in a group that addresses manage-ment of these alterations.

When the client is responding to hallucinations, respondto the feelings expressed in the client’s communication.

Respond to the client with “I” statements (“I do not seeor hear that”) when they request validation of halluci-nations. Do not argue with client’s experience.

Talk with the client about ways to distract him- or herselffrom the hallucinations, such as physical exercise,playing a game or a craft that takes a great deal of con-centration. [Note those activities preferred by the clienthere.]

When signs of the client’s hallucinating are present, assistthe client in initiating those activities or other controlbehaviors that have been identified by the client asuseful.

As the client’s condition improves, primary nurse willassist the client to identify onset of hallucinations andsituations that facilitate their onset.

As difficult situations are identified, primary nurse canbegin working with the client on alternative ways ofcoping with these situations. (Note alternative copingbehaviors selected by the client here.) Use relaxationtechniques to manage anxiety that focus on concretedirections and do not include open-ended visualiza-tions for clients who are currently experiencing sensoryperceptual alterations.

Refer the client and support system to appropriate sup-port systems in the community (e.g., Compeer).[Contact local mental health association for programsin your community.]

Arrange time with significant others to provide educationabout sensory–perceptual alterations and appropriateresponses to them.

Facilitates interaction, self-management, and monitoringof symptoms, and instills hope.72

Provides indirect confrontation of their experience.Preserves self-esteem while indicating that nurse doesnot experience the same stimuli.73

Reinforces new coping behaviors, and increases theclient’s perceived control.

Facilitates the development of alternative copingbehaviors.

Promotes the client’s sense of control and self-esteem.

Establishes continuity of responses and support for theclient after discharge.

Client outcomes are improved when support systems areprovided education and included in dischargeplanning.14,28

Gerontic Health

The nursing actions for the gerontic patient with this diagnosis are the same as those for the Adult Health patient.

Home Health


Teach the client and family measures to prevent sensorydeficit:

• Use of protective gear (e.g., goggles, sunglasses,earplugs, or special clothing in hazardous conditions toprevent radiation, sun, or chemical burns)

Family and client involvement in basic safety measuresenhances the effectiveness of preventive measures.



THOUGHT PROCESS, DISTURBED

DEFINITION2

A state in which an individual experiences a disruption incognitive operations and activities.


1. Cognitive dissonance2. Memory deficit or problems3. Inaccurate interpretation of environment4. Hypovigilance5. Hypervigilance6. Distractibility7. Egocentricity8. Inappropriate, nonreality-based thinking

RELATED FACTORS2

To be developed.


1. Dementia2. Neurologic diseases affecting the brain3. Head injuries4. Medication overdose, for example, digitalis, sedatives,

or narcotics5. Major depression6. Bipolar disorder, manic or depressive or mixed7. Schizophrenic disorders8. Dissociative disorders9. Obsessive–compulsive disorders

10. Paranoid disorder


••••••


Home Health


• Prevention of injuries to eyes, ears, skin, nose, andtongue

• Prevention of nutritional deficiencies• Close monitoring of medications that may be toxic to

the eighth cranial nerve• Correct use of contact lenses• Prevention of fluid and electrolyte imbalances

Involve the client and family in planning, implementing,and promoting correction or compensation for sensorydeficit [specify] by [date]:

• Family conference• Mutual goal setting• Communication (e.g., use of memorabilia and audio-

tapes or videotapes provided by family members tostimulate in cases of impaired communication)72

Assist the patient and family in lifestyle adjustments thatmay be required:

• Assistance with activities of daily living• Adjustment to and usage of assistive devices (e.g.,

hearing aid, corrective lenses, or magnifying glass)• Providing safe environment (e.g., protect kinestheti-

cally impaired individuals from burns)• Stopping substance abuse• Changes in family and work role relationships• Techniques of communicating with the individual with

auditory or visual impairment• Providing meaningful stimulation• Special transportation needs• Special education needs

Consult with or refer to appropriate assistive resources asindicated.

Involvement improves motivation. Communication andmutual goals increase the probability of positive out-comes.

Lifestyle changes require change in behavior. Self-evaluation and support facilitate these changes.

Use of existing community services provides for effectiveutilization of resources.


Thought Process, Disturbed 507

••••••

11. Delirium12. Eating disorders


Disturbed Sensory PerceptionThis diagnosis refers to deficits or overloads in sen-sory input. If the patient is having difficulty with sight,hearing, or any of the other senses, then a confusedpatient might well be the result. Double-check thepattern assessment to be sure sensory deficit is notthe primary problem.

Ineffective Health MaintenanceThe diagnosis of Disturbed Thought Process mightwell contribute to Ineffective Health Maintenance. In

this case, Disturbed Thought Process and IneffectiveHealth Maintenance would be companion diagnoses.

EXPECTED OUTCOME

Describes [number] of strategies to manage distortedthoughts by [date].

Will engage in reality based conversation for [number]minutes [number] times per day by [date].

Will be oriented to person, place, and time by [date].

TARGET DATES

A target date of 3 to 5 days is reasonable for this long-rangeproblem.


Adult Health


Monitor at least every 4 hours while awake:• Vital signs• Neurologic status, particularly for signs and symptoms

of ICP• Mental status• Laboratory values for metabolic alkalosis,

hypokalemia, increased ammonia levels, or infection

Consistently provide a safe, calm environment:• Provide siderails on bed.• Keep the room uncluttered.• Reorient the client at each contact.• Reduce extraneous stimuli (e.g., limit noise and visi-

tors, and reduce bright lighting).• Use touch judiciously.• Prepare for all procedures by explaining simply and

concisely.• Provide good lighting.• Have the family bring clock, calendar, and familiar

objects from home.

Design communications according to the patient’s bestmeans of communication (e.g., writing, visuals, orsound):

• Give simple, concise directions.• Listen carefully.• Present reality consistently.• Do not challenge illogical thinking.

Facilitate the patient’s use of prosthetic or assistivedevices (e.g., eyeglasses, dentures, hearing aid, orwalker).

Provide consistent approach in nursing care and routine.[Note routine for this client here.]

Assists in determining pathophysiologic causes forDisturbed Thought Process.

Basic safety measures and reinforcement of reality.

Enhances communication and quality of care.

Increases sensory input and reinforces reality.

Inspires trust, reinforces reality, decreases sensory stim-uli, and provides memory cues.




••••••


Adult Health


Facilitate self-care to the extent possible. [Note patient’sabilities here.]

Involve significant others in care, and include in teachingsessions. [Note teaching plan here.]

Refer to and collaborate with appropriate assistiveresources.

Collaborate with psychiatric nurse clinician and rehabili-tation nurse specialist.

Increases self-esteem, forces reality check, decreasespowerlessness, and provides a means of evaluating thepatient’s status.

Provides social support and consistency in management.

Provides for long-term support and a more holisticapproach to care.

Collaboration provides the best plan of care.

Child Health


Monitor cognitive capacity according to age and develop-mental capacity.

Note discrepancies in chronologic age and mastery ofdevelopmental milestones.

Provide ongoing reality orientation by encouraging thefamily to visit, and by emphasizing time, personalawareness, and gradual resumption of daily routine todegree possible.

Provide safety based on developmental needs. [Noteclient specific adaptations here.]

Facilitate family member’s expressions of concerns forthe child’s condition by allowing [number] minuteseach shift for discussion.

Provide for primary health needs, including administra-tion of medications, comfort measures, and control ofenvironment to aid in the child’s adaptation.

Structure the room in a manner that befits the child’sneeds.

*Keep room free of clutter with clear path for specialneeds.

Allow for ample rest and sleep periods according todevelopmentally appropriate guidelines. Note specificadaptations for this client here.

Monitor for altered coping and role performance.

Assist the family with discharge plans with referral tocommunity resources.

Basic data needed to plan individualized care.

As the patient attempts to reorient, it is helpful that date,time, and specific concrete planning, hour by hour, areoffered. The infant should be reintroduced to data, in acalm manner, that will assist in regaining some controlover the environment and in regaining the previousfunctioning level so that he or she can continue toprogress.

Disturbed Thought Process serves as a high-risk factorfor all involved. It would be a reasonable standard ofcare to increase all anticipatory safety efforts.

Promotes ventilation, which helps reduce anxiety andoffers insight into thoughts about the patient’s condi-tion.

Attention to regular health needs must also be consideredas the whole person is considered.

Keeping the environment adapted to personal needs willfacilitate care, minimize the chance for accidents, anddemonstrate the needed structure.

Rest is a key and essential consideration to provide opti-mal potential for cognitive–perceptual functioning.

All contributing factors must be explored to ensure meet-ing the patient’s needs.

Improves family adjustment and coping by assisting inpreparing for home needs. Empowerment then permitsthem the opportunity for growth in coping skills andparenting.



••••••


If institutionalization is required, assist the family inlearning about related issues, such as visitation, med-ical records maintenance, prognosis, and risk factors.

Allow for culturally unique aspects in management ofcare (e.g., respect for visitation on religious holidays,family wishes for diet, and bathing).

Provide for appropriate follow-up by making appoint-ments for next clinic visits.

Allow the family members opportunities for learning nec-essary care and mastery of content for long-term needs,such as resolution of conflicts related to institutional-ization or respite care and prognosis.

Planning provides the means for coping and adjusting tothe move with an opportunity for clarification.Provides advocacy for the patient and family.

Increases individuation and satisfaction with care. Showsrespect for the family’s values. Enhances nurse–patientrelationship.

Follow-up arrangements for clinic visits enhance the like-lihood of follow-up and demonstrate the importance ofthis follow-up care.

Anticipating learning needs serves to minimize crisesrelated to the child’s condition.

Women’s Health

This nursing diagnosis will pertain to the woman the same as any other adult, with the following exception. For midlifewomen, the nursing actions and interventions are the same as those given in Deficient Knowledge, Sleep Deprivation, andDisturbed Sleep Pattern under the headings perimenopausal and menopausal life periods.

Mental Health


Monitor the client’s level of anxiety, and refer to Anxiety(Chapter 8) for detailed interventions related to thisdiagnosis.

Speak to the client in brief, clear sentences.

Keep initial interactions short but frequent. Interact withclient for [number] minutes every 30 minutes. Beginwith 5-minute interactions and gradually increase thetimes of interactions.

Assign the client a primary care nurse on each shift toassume responsibility for gaining a relationship of trustwith the client.

Be consistent in all interactions with the client.

Set limits on inappropriate behavior that increases therisk of the client or others being harmed. [Note thelimits here as well as revisions to the limits.]

Initially place the client in an area with little stimulation.

Orient the client to the environment, and assign someoneto provide one-to-one interaction while the client ori-ents to unit.

Do not make promises that cannot be kept.

Inform the client of your availability to talk with him orher; do not pry or ask many questions.

Too much information can increase the client’s confusionand disorganization. The amount of time devoted tointeraction should be guided by the client’s attentionspan.73

Facilitates the development of a trusting relationship.


Facilitates the development of a trusting relationship, andmeets the client’s safety needs.

Client and staff safety are of primary importance.

Inappropriate levels of sensory stimuli can contribute toclient’s sense of disorganization and confusion.

Promotes the client’s safety needs while facilitating thedevelopment of a trusting relationship.






••••••


Mental Health


Do not argue with the client about delusions; inform theclient in a matter-of-fact way that this is not your expe-rience of the situation (e.g., “I do not think I am angrywith you.”)

Recognize and support the client’s feelings (e.g., “Yousound frightened.”)

Respond to the feelings being expressed in delusions orhallucinations.

Initially have the client involved in one-to-one activities;as condition improves, gradually increase the size ofthe interaction group. [Note current level of function-ing here.]

Have the client clarify those thoughts you do not under-stand. Do not pretend to understand that which you donot.

Do not attempt to change delusional thinking withrational explanations.

After listening to delusion once, do not engage in conver-sations related to this material or focus conversationson this material.

Focus conversations on here-and-now content related toreal things in the environment or to activities on theunit.

Do not belittle or be judgmental about the client’s delu-sional beliefs.

Avoid nonverbal behavior that indicates agreeing withdelusional beliefs.

When the client’s behavior and anxiety level indicatereadiness, place the client in small-group situations.Do not put clients who are actively hallucinatingin groups. The client will spend [number] minutesin group activities [number] times a day.

(Time and frequency will increase as the client’s abilityto cope with these situations improves.)

Develop a daily schedule for the client that encouragesfocus on “here and now” and is adapted to the client’slevel of functioning so that success can be experienced.Note daily schedule here.

Assign the client meaningful roles in unit activities.Provide roles that can be easily accomplished by theclient to provide successful experiences. [Note clientresponsibilities here.]

Primary nurse will spend [number] minutes with theclient twice a day to discuss the client’s feelings andthe effects of the delusions on the client’s life.(Number of minutes and the degree of exploration ofthe client’s feelings will increase as the client developsrelationship with nurse.)

Argument may reinforce the client’s need to maintain thedelusional system and interferes with the developmentof a trusting relationship.

Focuses on the client’s real feelings and concerns.

High levels of environmental stimuli may increase confu-sion and disorganization.

Facilitates the development of a trusting relationship, andprevents inadvertent support of the delusional thinking.

This may encourage the client to cling to these thoughts.

Decreases the possibility of supporting or reinforcing thedelusion.

Facilitates the client’s contact with reality.69

Protects the client’s self-esteem.

Decreases the possibility of supporting or reinforcing thedelusion.

Provides feedback about delusional beliefs from peers.

Facilitates the client’s contact with reality. Promotes posi-tive self-image.

Facilitates the client’s contact with reality. Promotes posi-tive self-image.

Assists in the development of alternative copingbehaviors.



••••••


Provide rewards to the client for accomplishing taskprogress on the daily schedule. These rewards shouldbe ones the client finds rewarding.

Spend [number] minutes twice a day walking with theclient. This should start at 10-minute intervals andgradually increase. This can be replaced by any physi-cal activity the client finds enjoyable. A staff membershould be with the client during this activity to providesocial reinforcement to the client for accomplishing theactivity.

Arrange a consultation with the occupational therapist toassist the client in developing or continuing specialinterests.

Monitor delusional beliefs for potential of harming self orothers.

Note any change in behavior that would indicate a changein the delusional beliefs that could indicate a potentialfor violence.

If the client is placed in seclusion, interact with the clientat least every 15 minutes.

Maintain environment that does not stimulate the client’sdelusions (e.g., if the client has delusions related toreligion, limit discussions of religion and religiousactivity on unit to very concrete terms). Limit interac-tion with persons who stimulate delusional thinking.

The primary nurse will assist the client in identifyingsigns and symptoms of increasing thought disorganiza-tion and in developing a plan to cope with these situa-tions before they get out of control. This will be donein the regularly scheduled interaction times betweenthe primary nurse and the client.

As the client’s condition improves, primary nurse willassist the client to identify onset delusions with periodsof increasing anxiety.

As connection is made between thought disorder andanxiety, the client will be assisted to identify specificanxiety-producing situations and learn alternative cop-ing behaviors. See Anxiety (Chapter 8) for specificinterventions.

Teach client strategies to manage the thoughts that pre-cede increases in anxiety by:

• Linking increase in anxiety to dysfunctional thinking• Thought stopping techniques (wearing rubber band on

wrist and snapping it when negative thoughts occur)• Rehearse changes in self-talk that would decrease anxi-

ety (replace words like should, never, and always withmore reality based thinking). Refer to resources onCognitive therapy for more techniques.19

Refer the client to outpatient support systems, and assistwith making arrangements for the client to contactthese before discharge.

Positive feedback encourages productive behavior.

Facilitates the development of a trusting relationship.Social interaction provides positive reinforcement.Helps increase daytime wakefulness, promoting a nor-mal sleep–wake cycle.

Increases daytime wakefulness, maintaining a normalsleep-rest cycle.

Patient and staff safety are of primary concern.

Patient and staff safety are of primary concern.

Provides reality orientation, and assists the client withcontrolling hallucinations and delusions.

Excessive environmental stimuli can increase confusionand disorganization.


Facilitates the client’s developing alternative copingbehaviors.


Facilitates the client’s reintegration into the community.




••••••


Gerontic Health

● N O T E : Problems related to Disturbed Thought Process with older adults may pres-ent themselves in various ways. Two conditions, dementia and delirium, are consideredhere. Irreversible dementia, such as Alzheimer’s or multi-infarct dementia, is usuallyprogressive, gradual in onset, of long duration, and has a steady downward course.Delirium, or acute confusional state, presents with acute onset, is of short duration, andhas a fluctuating course and is often reversible with treatment.74 Nursing interventionsvary depending on the cause of the Disturbed Thought Process.


DementiaConduct a thorough assessment and collaborate with the

health-care team to treat possible etiologies of demen-tia: metabolic diseases, toxin exposure, infection, neo-plasm, drug side effects, nutritional deficiencies,degenerative neurologic disease, cerebral vascularinjury.

Offer immediate attention with supportive and sympto-matic care.

Assure continuity of care personnel.

Support sensory function in all stages of dementia byusing assistive devices such as glasses, hearing aids,and dentures.

Maintain safe environment. Avoid leaving solutions,equipment, or medications near the patient that couldresult in injury through misuse or ingestion.

Provide a consistent environment and schedule butremain flexible.

Communicate with the client using verbal or nonverbalstrategies as appropriate for the stage of dementia.

Monitor environment to prevent overstimulating thepatient with light, sounds, and frequent activity.Support sensory function in all stages of dementia byusing assistive devices such as glasses, hearing aids,and dentures.

Provide appropriate environmental cues and limit inap-propriate environmental cues.

For example, when preparing a client to bathe, place tow-els and clean clothing in a visible location. This pro-vides an environmental cue for the activity of bathing.

• Limit the client’s exposure to cues such as keys, ovenknobs, or cooking utensils if they stimulate the client toengage in activities that are not appropriate or safe.

Schedule activities that are of short duration (usually 20-minute sessions). [Note client’s schedule here.]

Use short sentences and clear directions when communi-cating with the patient.

To facilitate treatment of the primary problem.

Prevent further disturbed thought processes.

Facilitates feelings of safety by client, allows for earlyidentification of changes in client mental status.

Minimizes sensory sources of disturbed thoughtprocesses.

Basic preventive measure.

Prevents exacerbation of disturbed thought processes.

Clients with middle stage Alzheimer disease often havedifficulty understanding or expressing verbally. Late-stage Alzheimer’s clients often lose their ability tocommunicate verbally.

With dementia, the patient has a reduced threshold forstress.

Prevents stresses on an individual already suffering fromattention deficits and anxiety.

Allows processing of basic information withoutdistraction.



••••••


Determine self-care abilities that are intact, and encour-age continued participation in these activities.

Monitor food and fluid intake to determine that nutri-tional status is adequate.

Provide consistent staff.Refer the family to local Alzheimer’s and related disease

support groups.

DeliriumMonitor for conditions that can induce delirium.

Provide orienting information to the patient as often asnecessary.

Provide sensory stimulation such as bathing, touching,and back massages.

Provides stimulation and sense of pride. Promotes physi-cal activity.

Reduces anxiety.Provides long-term support.

Certain factors such as electrolyte imbalance, preopera-tive dehydration, unanticipated surgery, intraoperativehypotension, postoperative hypothermia, and a largenumber of medications have been found to be associ-ated with acute confusional states in older adults.75,76

Provides information to the patient about the current situ-ation, and assists in reducing anxiety and confusion.

Assists in restoring the patient’s sense of body image.77

Home Health

In addition to the following interventions, the interventions for Adult Health can be applied to the home health client.


Teach the client and family to monitor for signs andsymptoms of Disturbed Thought Process:

• Poor hygiene• Poor decision making or judgment• Regression in behavior• Delusions• Hallucinations• Changes in interpersonal relationship• Distractibility

Involve the client and family in planning, implementing,and promoting appropriate thought processing:


Assist the client and family in lifestyle adjustments thatmay be necessary:

• Providing safety and prevention of injury• Frequent orientation to person, place, and time• Providing reality testing and patient verification• Assisting in working through alterations in role func-

tions in family or at work• Stopping substance abuse• Facilitating family communication• Setting limits• Learning new skills• Decreasing risk for violence• Preventing suicide• Explaining possible chronicity of disorder

Basic monitoring that allows for early intervention.

Involvement improves cooperation and motivation,thereby increasing the probability of an improvedoutcome.



UNILATERAL NEGLECT

DEFINITION2

Lack of awareness and attention to one side of the body.2


1. Consistent inattention to stimuli on an affected side2. Does not look toward affected side3. Positioning and/or safety precautions in regard to the

affected side4. Inadequate self-care5. Leaves food on plate on the affected side

RELATED FACTORS2

1. Effects of disturbed perceptual abilities, for example,hemianopsia

2. Neurologic illness or trauma3. One-sided blindness


1. Cerebrovascular accident2. Glaucoma3. Blindness secondary to diabetes mellitus

4. Spinal cord injury5. Amputation6. Ruptured cerebral aneurysm7. Brain trauma


Disturbed Sensory PerceptionThis diagnosis refers to a problem with receiving sen-sory input and interpretation of this input. UnilateralNeglect could be, as indicated by the related factors,an outcome of this disturbance in sensory inputand/or perception of this input.

EXPECTED OUTCOME

Performs self-care of all body parts by [date].Verbalizes plan to address self-care deficits by [date].Identifies [number] of needs for assistance by [date].

TARGET DATES

A target date between 5 and 7 days would be appropriate toevaluate initial progress.


••••••


Home Health


• Referring the client to community resources for finan-cial assistance

• Reducing sensory overload• Teaching stress management• Teaching relaxation techniques• Referring the client and family to support groups

Assist the client and family to set criteria to help themdetermine when professional intervention is required.

Teach the client and family purposes, side effects, andproper administration techniques for medications.

Consult with or refer to appropriate assistive resources asrequired.

Early identification of issues requiring professional evalu-ation will increase the probability of successful inter-ventions.

Provides necessary information for the client and familythat promotes safe self-care.

Efficient and cost-effective use of community resources.


Adult Health


Ensure patient safety. Raise siderails on affected side.

Assist patient in self-care

Adapt environment deficiency, place items onunaffected side.

Provides basic safety.


Unilateral Neglect 515

••••••


Frequently remind the patient to attend to both sides ofhis or her body.

Consult with physical and occupational therapy to facili-tate patient’s awareness of and articulate sensations onneglected side. [Note support from nursing neededhere.]

Assist the patient with ROM exercises to neglected sideof body every 4 hours while awake at [times]. Teachthe extent of movement of each joint on the neglectedside of body.

Help the patient position neglected side of body in a simi-lar way as attended side of body whenever position ischanged.

Refer to rehabilitation nurse clinician.

Repetition improves brain processing.

Increases brain’s awareness of neglected side.

Increases brain’s awareness of neglected side, and main-tains muscle tone and joint mobility.

Collaboration provides a more holistic plan of care, andrehabilitation nurse will have most up-to-date knowl-edge regarding this diagnosis.

Child Health

See nursing actions under Disturbed Sensory Perception in addition to those listed here.


Allow 30 minutes every shift for the patient and family toexpress how they perceive the unilateral neglect.

Determine how the unilateral neglect affects the usualexpected behavior or development for the child.

Monitor for presence of secondary or tertiary deficits.

Establish, with family input, appropriate anticipatorysafety guidelines that are based on the unilateral neg-lect and the developmental capacity of the child.

Stress appropriate follow-up prior to dismissal from hos-pital with appropriate time frame for the family.

Ventilation of feelings is paramount in understanding theeffect the problem has on the patient and the family; itis also critical as a means of evaluating needs.

Previous and/or current developmental capacity may beaffected by the unilateral neglect depending on thedegree of severity. To be able to judge the best meansof therapy requires these data to be considered (e.g.,does the child use the affected hand as a helper, or nottry to use it at all?)

Identification of primary deficits should alert all to moni-tor for possible secondary and tertiary deficits to mini-mize further sequelae, which can be treated early.

Safety needs and measures must reflect the developmen-tal capacity of the child and slightly beyond it. There isa special need to structure the environment to allow forappropriate exploratory behavior while maintainingsafety without overprotection.

Arrangement for follow-up increases the likelihood ofcompliance and shows the importance of follow-up.

Women’s Health

This nursing diagnosis will pertain to women the same as any other adult.

Mental Health

Nursing interventions for this diagnosis are those described in Adult Health.(care plan continued on page 516)



••••••


Gerontic Health

The interventions for Adult Health can be applied to the aging client.

Home Health



Monitor for factors contributing to Unilateral Neglect(e.g., disturbed perceptual abilities, neurologic disease,or trauma).

Involve the client and family in planning, implementing,and promoting reduction in effects of UnilateralNeglect:

• Schedule family conferences (e.g., to discuss concernsfamily members have).

• Encourage the family’s ideas for addressing theconcern.

• Set mutual goals (e.g., establish two measures to offsetthe effect of unilateral neglect). Be sure roles for theparticipants are identified.

• Maintain communication.• Provide support for the caregiver (e.g., plan respite

time for the primary caregiver). Alternate caregivers areidentified and trained.

Teach the client and family measures to decrease effectsof Unilateral Neglect:

• Active and passive ROM exercises• Ambulation with assistive devices (canes, walkers, or

crutches)• Objects placed within field of vision and reach• Assistive eating utensils• Assistive dressing equipment• Safe environment (e.g., objects removed from area out-

side field of vision)Assist the family and client to identify lifestyle changes

that may be required:• Change in role functions• Coping with disability or dependency• Obtaining and using assistive equipment• Coping with assistive equipment• Maintaining safe environment


This action provides the database needed to identify inter-ventions that will prevent or diminish UnilateralNeglect.

Family involvement is important to ensure success.Communication and mutual goals improve theoutcome.

These actions diminish the negative effects of UnilateralNeglect.

Lifestyle changes require changes in behavior. Self-evaluation and support facilitate these changes.

Appropriate use of existing community services is effec-tive use of resources.

R E F E R E N C E S

1. Murray, RB, and Zentner, JP: Health Assessment and PromotionStrategies Through the Life Span, ed 6. Appleton & Lange, Norwalk,CT, 1997.


3. Eisenhart, K: New perspectives in the management of adults withsevere head injury. Crit Care Nurs Q 17:1, 1994.

4. Walleck, CA: Preventing secondary brain injury. AACN Clin IssuesCrit Care Nurs 3:19, 1992.

5. Hickey, JV: The Clinical Practice of Neurological and NeurosurgicalNursing, ed 4. JB Lippincott, Philadelphia, 1997.

6. Kerr, M, et al: Head-injured adults: Recommendations for endotrachealsuctioning. J Neurosci Nurs 25:86, 1993.


7. Crosby, LJ, and Parsons, LC: Cerebrovascular response of closedhead-injured patients to a standardized endotracheal tube suctioningand manual hyperventilation procedure. J Neurosci Nurs 24:40, 1992.

8. Rising, CJ: The relationship of selected nursing activities to ICP. JNeurosci Nurs 25:302, 1993.

9. Barsevick, A, and Llewellyn, J: A comparison of the anxiety-reducingpotential of two techniques of bathing. Nurs Res 31:22, 1982.

10. Author: Part I. Guidelines for the management of severe traumaticbrain injury. In: Management and prognosis of severe traumaticbrain injury. (2) Update notice. Guidelines for the management ofsevere traumatic brain injury: Cerebral perfusion pressure. AmericanAssociation of Neurological Surgeons—Medical Specialty Society,Brain Trauma Foundation—Disease Specific Society. 2000 (revised2003). 165 pages. National Guidelines Clearinghouse: 003020.

11. Hockenberry, MJ: Wong’s Essentials of Pediatric Nursing, ed 7. CVMosby, St. Louis, 2006.

12. Moss, SW: The power to terrify: Eclampsia in 19th-CenturyAmerican Practice. JOGNN J Obstet Gynecol Neonatal Nurs 31:5,514, 2002.

13. Lowdermilk, DL, and Perry, SE: Maternity and Women’s Health Care,ed 8. CV Mosby, St. Louis, 2004.

14. Kidner, MC, and Flanders-Stepans, MB: A model for the HELLP syn-drome: The maternal experience. JOGNN J Obstet Gynecol NeonatalNurs 33(1):44, 2004.

15. Varacarolis, EM: Foundations of Psychiatric–Mental Health Nursing,ed 3. WB Saunders, Philadelphia, 1998.

16. Author, The Agency for Healthcare Research and Quality in theUnited States, Clinical practice guidelines, abstracts,http://www.guideline.gov 2006.

17. Maxmen, JS: Psychotropic Drugs Fast Facts, ed 3. WW Norton, NewYork, 2002.

18. Mahoney, DF: Analysis of restraint free nursing homes. Image 33:155,1995.

19. Kneisl, C, Wilson, H, and Trigoboff, E: Contemporary Psychiatric–Mental Health Nursing. Pearson Education, Upper Saddle River, NJ,2004.

20. McCloskey, J, Dochterman, J, and Bulechek, G: Nursing InterventionsClassification, ed 4. CV Mosby, St. Louis, 2004.

21. Weinrich, S, et al: Agitation: Measurement, management, and inter-vention Res Arch Psychiatr Nurs 9:251, 1994.

22. Roberto, K, et al: Communication patterns between caregivers andtheir spouses with Alzheimer’s disease: A case study. Arch PsychiatrNurs 12:202, 1998.

23. Sullivan-Marx, E: Delirium and physical restraint in the hospitalizedelderly. Image 26:295, 1994.

24. Erickson, H, Tomlin, E, and Swain, M: Modeling and Role Modeling:Theory, Practice and Research. Society for the Advancement ofModeling and Role-Modeling, Austin, TX, 1990.

25. Hall, E: The role of oxygen radicals in traumatic injury: Clinicalimplications. J Emerg Med 11:31, 1993.

26. Harvath, TA, et al: Dementia-related behaviors. J Psychosoc Nurs33:35, 1994.

27. Goldsmith, SM, Hoeffer, B, and Rader, J: Problematic wanderingbehavior in the cognitively impaired elderly. J Psychosoc Nurs 33:6,1994.

28. Veterans Administration, DOD (2004). Management of Persons withPsychoses. National Guideline Clearing House, 2006.

29. Kaye, P: Notes on Symptom Control in Hospice and Palliative Care.Hospice Education Institute, Essex, CT, 1990.

30. Zyzanski, S, and Kodish, E: Committee on Bioethics, AmericanAcademy of Pediatrics, Informed consent, parental permission, andassent in pediatric practice. 95:314, 2006.

31. Teschendorf, M: Women during the reproductive years. In Breslin, ET,and Lucas, VA (eds): Women’s Health Nursing: Toward Evidenced-Based Practice. Saunders, Philadelphia, 2003.

32. Krause, KD, and Younger, VJ: Nursing diagnoses as guidelines in thecare of the neonatal ECMO patient. J Obstet Gynecol Neonatal Nurs21:176, 1992.

33. Cox, BE: What if? Coping with unexpected outcomes. ChildbirthInstructor 1:24, 1991.

34. Parkman, SE: Helping families to say good-bye. MCN Am J MaternChild Nurs 17:14, 1992.

35. Ryan, PF, Cote-Arsenault, D, and Sugarman, LL: Facilitating careafter perinatal loss: A comprehensive checklist. J Obstet GynecolNeonatal Nurs 20:385, 1991.

36. Ladebauche, P: Unit-based family support groups: A reminder. MCN:Am J Matern Child Nurs 17:18, 1992.

37. Cote-Arsenault, D, and Mahlangu, N: Impact of perinatal loss on thesubsequent pregnancy and self: Women’s experiences. JOGNN JObstet Gynecol Neonatal Nurs 28:274, 1999.

38. DeMontigny, F, Beauder, L, and Duman, L: A baby has died: Theimpact of perinatal loss on family social networks. JOGNN J ObstetGynecol Neonatal Nurs 28:151, 1999.

39. Erickson, MH: The Practical Applications of Medical and DentalHypnosis. Brunner & Mazel, New York, 1990.

40. Keeney, BP: Aesthetics of Change. Guilford Press, New York, 1983.41. Watzlawick, P, Weakland, J, and Fisch, R: Change. WW Norton, New

York, 1974.42. Aguilera, DC: Crisis Intervention: Theory and Methodology, ed 8. CV

Mosby, St. Louis, 1998.43. Black, HC: Black’s Law Dictionary, ed 6. West Publishing, St. Paul,

MN.44. Creasia, JL, and Parker, B: Conceptual Foundations of Professional

Nursing Practice, ed 2. Mosby–Year Book, St. Louis, 1996.45. Simmonds, KE, and Likis, FE: Providing options counseling for

women with unintended pregnancies. JOGNN J Obstet GynecolNeonatal Nurs 34(3):373, 2005.

46. Nelson, AM: Transition to motherhood. JOGNN J Obstet GynecolNeonatal Nurs 32(4):465, 2003.

47. Martell, LD: Postpartum women’s perceptions of the hospitalenvironment. JOGNN J Obstet Gynecol Neonatal Nurs 32(4):478,2003.

48. Groer, MW, Davis, MW, and Hemphill, J: Postpartum stress: Currentconcepts and the possible protective role of breastfeeding. JOGNN JObstet Gynecol Neonatal Nurs 31(4):411, 2002.

49. Swift, K, and Janke, J: Breast binding…Is it all that it’s wrappedup to be? JOGNN J Obstet Gynecol Neonatal Nurs 32(3):332, 2003.

50. Bowman, KG: Postpartum learning needs. JOGNN J Obstet GynecolNeonatal Nurs 34(4):438, 2005.

51. Buist, A, Morse, CA, and Durkin S: Men’s adjustment to fatherhood:Implications for obstetric health care. JOGNN J Obstet GynecolNeonatal Nurs 32(2):172, 2003.

52. de Montigny, F, and Lacharite, C: Fathers’ Perceptions of the imme-diate postpartal period. JOGNN J Obstet Gynecol Neonatal Nurs33(3):328, 2004.

53. St. John, W, Cameron, C, and McVeigh, C: Meeting the challengeof new fatherhood during the early weeks. JOGNN J Obstet GynecolNeonatal Nurs 34(2):180, 2005.

54. Matthey, S, Morgan, M, Healey, L, Barnett, B, Kavanagh, DJ, andHowie, P: Postpartum issues for expectant mothers and fathers.JOGNN J Obstet Gynecol Neonatal Nurs 31(4):428, 2002.

55. Vliet, EL: Screaming to be Heard: Hormonal Connections WomenSuspect and Doctors Ignore. M. Evans and Co., New York, 1995.

56. Lindsay, SH: Menopause naturally: Exploring alternatives to tradi-tional HRT. Lifelines 3:32, 1999.

57. Learn, CD, and Higgins, PG: Harmonizing herbs: Managingmenopause with help from Mother Earth. Lifelines 3:39, 1999.

58. Wright, L, and Leahey, M: Nurses and families: A guide to familyassessment and intervention, ed 4. F.A. Davis, Philadelphia, 2005.

59. Newfield, S, Lewis, D, and Newfield, N: Facilitating lifestyle change:An approach to patient education. Unpublished, 2000.

60. Huebscher, R: Natural, Alternative, and Complementary HealthCare. In Breslin, ET, and Lucas, VA (eds): Women’s HealthNursing: Toward Evidence-Based Practice. WB Saunders, St.Louis, 2003.

61. Burns, M: Screening and Diagnostic Tests. In Breslin, ET, and Lucas,VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.WB Saunders, St. Louis, 2003.

62. Fogel, CI, and Woods, NF: Health Care of Women: A NursingPerspective. CV Mosby, St. Louis, 1981.

63. Hinz, M, and Leick, M: Identifying the five most common nursingdiagnoses utilized in labor and delivery, unpublished presentation,14th Biennial Conference on Nursing Diagnosis, Orlando, Florida,April 8, 2000.

64. Author: Database of Clinical Practice Guidelines, The Agency forHealthcare Research and Quality in the United States,http://www.guideline.gov, 2006.

65. Maas, M, Buckwalter, KC, and Hardy, MA: Nursing Diagnosis andInterventions for the Elderly. Addison-Wesley, Redwood City, CA,1991.

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66. Ferrell, B, and Ferrell, B: Easing the pain. Geriatric Nursing 11:175,1990.

67. Hofland, S: Elder beliefs: Blocks to pain management. J GerontolNurs 18:19, 1992.

68. Haber, J, et al: Comprehensive Psychiatric Nursing, ed 5. Mosby–YearBook, St. Louis, 1997.

69. Puskar, KR, et al: Psychiatric nursing management of medication-freepsychotic patients. Arch Psychiatri Nurs 4:78, 1990.

70. Townsend, M: Nursing Diagnosis in Psychiatric Nursing, ed 5. FADavis, Philadelphia, 2001.

71. Schwartz, MS, and Shockley, EL: The Nurse and the Mental Patient.Russell Sage Foundation, New York, 1956.

72. Buccheri, R, et al: Auditory hallucinations in schizophrenia. JournalPsychosocial Nursing 34:12, 1996.

73. Dochtermann, McCloskey, J, and Bulechek, G: Nursing InterventionsClassification, ed 4. Mosby–Year Book, St. Louis, 2004.

74. Gomez, G, and Gomez, E: Dementia? Or delirium? Geriatr Nurs11:136, 1989.

75. Foreman, M: Complexities of acute confusion. Geriatric Nurs 11:136,1990.

76. Bowman, AM: The relationship of anxiety to development of postoperative delirium. J Gerontol Nurs 18:24, 1992.

77. Faraday, K, and Berry, M: The nurse’s role in managing reversibleconfusion. J Gerontol Nurs 15:17, 1989.


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8SELF-PERCEPTIONAND SELF-CONCEPTPATTERN1. ANXIETY 530

2. BODY IMAGE, DISTURBED 541

3. DEATH ANXIETY 548

4. FEAR 553

5. HOPELESSNESS 562

6. LONELINESS, RISK FOR 569

7. PERSONAL IDENTITY, DISTURBED 575

8. POWERLESSNESS, RISK FOR AND ACTUAL 579

9. SELF-CONCEPT, READINESS FOR ENHANCED 586

10. SELF-ESTEEM: CHRONIC LOW, SITUATIONAL LOW,AND RISK FOR SITUATIONAL LOW 590

11. SELF-MUTILATION, RISK FOR AND ACTUAL 598


PATTERN DESCRIPTION

As the nurse interacts with the client, the most importantknowledge the client contributes is self-knowledge. It is thisunderstanding, most often labeled “self-concept,” that deter-mines the individual’s manner of interaction with others.One’s self-concept is composed of beliefs and attitudesabout the self, including perception of abilities (cognitive,affective, or physical), body image, identity, self-esteem,and general emotional pattern.1 An individual’s behavior isaffected not only by experiences prior to interactions withthe health-care system, but also by interactions with thehealth-care system.

PATTERN ASSESSMENT

1. Does the patient express concern the regarding currentsituation?a. Yes (Anxiety or Fear)b. No

2. Can the patient identify the source of concern?a. Yes (Fear)b. No (Anxiety)

3. As a result of this admission, will the patient goinghave a change in body structure or function?a. Yes (Disturbed Body Image)b. No

4. Does the patient verbalize a change in lifestyle as aresult of this admission?a. Yes (Disturbed Body Image)b. No

5. Does the patient express fear about dying?a. Yes (Death Anxiety)b. No

6. Does the patient express worries about the impact ofhis or her death on his or her family and/or friends?a. Yes (Death Anxiety)b. No

7. Does the patient verbalize a negative view of self?a. Yes (Situational Low Self-Esteem)b. No (Readiness for Enhanced Self-Concept)

8. Does the patient believe he or she can deal with thecurrent problem that led to this admission?a. Yesb. No (Situational Low Self-Esteem)

9. Does the patient or his or her family indicate that theself-negating impression is a long-standing (severalyears) problem?a. Yes (Chronic Low Self-Esteem)b. No (Situational Low Self-Esteem)

10. Does the patient question who he or she is or verbalizelack of an understanding regarding his or her role inlife?a. Yes (Disturbed Personal Identity)b. No (Readiness for Enhanced Self-Concept)

11. Does the patient appear passive or verbalize passivity?a. Yes (Hopelessness)b. No

12. Does the patient demonstrate decreased verbalizationand/or flat affect?a. Yes (Hopelessness)b. No

13. Does the patient have a problem with physical or socialisolation?a. Yes (Risk for Loneliness)b. No (Readiness for Enhanced Self-Concept)

14. Has the patient recently suffered the loss of a signifi-cant other?a. Yes (Risk for Loneliness)b. No

15. Does the patient verbalize lack of control?a. Yes (Powerlessness)b. No

16. Is the patient participating in care and decision makingregarding care?a. Yes (Readiness for Enhanced Self-Concept)b. No (Powerlessness)


Definition of the self and of a self-concept has been an issueof debate in philosophy, sociology, and psychology formany years, and many publications are available on thistopic.2 The complexity of the problem of defining self iscompounded by the knowledge that external observationprovides only a superficial glimpse of the self, and intro-spection requires that the “knower” knows himself or herselfso that information actually gained is self-referential. Inspite of these problems, the concept continues to be perva-sive in the literature and in the universal experience of “self”or “not self.” Intuitively one would say, of course, “There isa self because I have experiences separate from those aroundme; I know where I end and they begin.” The importanceof self is also emphasized by the language in the multitudeof self-referential terms such as self-actualization, self-affirmation, ego-involvement, and self-concept.

Cognitive neuroscientists have utilized brain imagingduring various self-referential tasks to understand theprocess of experiencing the self. This research has linkedspecific areas of the brain with activities of self-reference.3

The medial prefrontal cortex is one area that demonstratesthe most activity when thinking about the self. It is hypoth-esized that this area links multiple self-knowledge systemsin the brain.3 Clearly, the neurological response is differentwhen one is thinking of the self, and this process changes aswe develop a better self-concept.4 The understandingsevolving from cognitive neuroscience provide a map to theintricacies of self-knowledge, which can inform client care.

Some of the basic neuroscience understandings withimplications for intervening with human responses relatedto self-perception are related to the awareness of one’s own

520 Self-Perception and Self-Concept Pattern

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body. This is the foundational understanding of the self, toknow where the physical self begins and ends. The processof knowing this occurs when the neuro command to move abody part is issued. At this point two signals are sent, one tothe body part that needs to be moved, and one to the part ofthe brain that monitors movement. The monitoring processpredicts the action experience. If the prediction does notmatch what is experienced, and the difference cannot be rec-onciled, then the brain processes this as not caused by theself.4 Difficulties in making this link could result in a dis-turbed body image or delusional thinking. The client, insearch of an explanation for his or her experience, couldconclude that someone or something outside of him- or her-self is controlling his or her actions. Continued research incognitive neuroscience will increase understanding abouthow to facilitate the development of self-knowledge linksand assist in refining nursing interventions.

Neuroscientists recognize that humans have devel-oped a uniquely complex sense of self. The evolution of thiscomplexity may have been a response to living in complexsocial networks.4 This connection between the brain andsocial networks reflects the circular causal model of sys-tems/cybernetics that provides the theoretical foundation forthe research.3 In that circular wholistic perspective, the soci-ological understandings of the development of the self mustalso be considered.

Turner5 addresses society’s need for the individual toconceptualize the self-as-object. Recognizing the self-as-object allows society to place responsibility, which becomesa very valuable asset in maintaining social control and socialorder. This returns us to the initial problem of what the self isand how we can understand others’ selves and ourselves.6 Inthis section, the assumption is made that self-concept refersto the individual’s subjective cognitions and evaluations ofself; thus, it is a highly personal experience. This indicatesthat the self is a personal construct and not a fact or hard real-ity. It is further assumed that the individual will act, as statedearlier, in congruence with the self-concept. This conceptual-ization is consistent with the authors who will be discussed,and with the assumptions utilized in psychological research.6

It is also important to recognize that language assists indeveloping a concept. This becomes crucial when thinkingabout the concept of self in English, because the English lan-guage comes from a tradition of Cartesian dualism that doesnot express integrated concepts well. Often it will appear thatthe information presented is separating the individual intovarious parts, when, in fact, an integrated whole is beingaddressed. For example, James7 talks about an “I” and a“Me.” If these terms were taken at face value, it would appearthat the individual is being divided into multiple parts, when,in fact, an integrated whole is being discussed. The wordsdescribe patterns of the whole person. Unless otherwisestated, it can be assumed that the concepts presented in thisbook reflect on the individual as an integrated whole.

Symbolic interaction theory provides a basis forunderstanding the self. James7 and Mead8 developed the

foundation for the self in this theoretical model. James out-lines the internal working of the self with his concepts of “I”and “Me.” “I” is the thinker or the state of consciousness.“Me” is what the “I” is conscious of, and includes all ofwhat people consider theirs. This “Me” contains threeaspects: the “material me,” the “social me,” and the “spiri-tual me.”6 The self-construction outlined by Mead8 indicatesthat there is the “knower” part of the self and that which the“knower” knows. Mead conceptualizes the thoughts them-selves as the “knower” to resolve the metaphysical problemof who the “I” is. In Mead’s writings, the consciousness ofself is a stream of thought in which the “I” can rememberwhat came before and continues to know what was known.Mead8 expressly addresses the development of these memo-ries and how they affect one’s behavior.

Mead8 describes the self-concept as evolving out ofinteractions with others in social contexts. This processbegins at the moment of birth and continues throughout alifetime. The definition of self can occur only in social inter-actions, for one’s own self exists only in relation to otherselves. The individual is continually processing the reac-tions of others to his or her actions and reactions. This pro-cessing is taking place in a highly personalized manner, forthe information is experienced through the individual’sselective attention, which is guided by the current needs thatare struggling to be expressed. This results in an environ-ment that is constructed by one’s perceptions. Mead’s con-ceptualization leads to an interesting feedback process inthat we can only perceive self as we perceive others perceiveus. This continues to reinforce the idea that the self-conceptis highly personalized.

Many authors5,7,8 have addressed the process of devel-oping a concept of self. The model developed by HarryStack Sullivan9 is presented here because it is consistentwith the information presented in the symbolic interactionliterature, and is used as the theoretical base in much of thenursing literature.

Sullivan9 describes the self-concept as developing ininteractions with significant others. Sullivan sees develop-ment of the self-concept as a dynamic process resultingfrom interpersonal interactions that are directed towardmeeting physiologic needs. This process has its most obvi-ous beginnings with the infant and becomes more complexas the individual develops. This increasing complexityresults from the layering of experiences that occurs in thedeveloping individual. The biologic processes become lessand less important in directing the individual the furtheraway from birth one is and as the importance of interper-sonal interaction increases. The initial interpersonal interac-tion is between the infant and the primary caregivers. Aninfant expresses discomfort with a cry and the “parentingone” responds. This response, whether tender or harsh,begins to influence the infant’s beliefs about herself or him-self, as well as the world in general. If the interaction doesnot provide the infant with a feeling of security, anxietyresults and interferes with the progress toward other life


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goals. Sullivan makes a distinction between the inner expe-rience and the outer event and describes three modes ofunderstanding experience.

The first developmental experience is the prototaxicmode. In this mode, the small child experiences self and theuniverse as an undifferentiated whole. At 3 to 4 months, thechild moves into the parataxic mode. The parataxic modepresents experiences as separated but without recognition ofa connectedness or logical sequence. Finally, the individualenters the syntaxic mode, in which consensual validation ispossible. This allows for events and experiences to be com-pared with others’ experiences and for establishment ofmutually understandable communication instead of the autis-tic thinking that has characterized the previous stages.10,11

As one experiences the environment through thesethree modes of thought, the self-system or self-concept isdeveloped. Sullivan conceptualized three parts of the self.The part of the self that is associated with security andapproval becomes the “good me,” whereas that which iswithin one’s awareness, but is disapproved of, becomes the“bad me.” The “bad me” could include those feelings, needs,or desires that stimulate anxiety. Those feelings and under-standings that are out of awareness are experienced as “notme.” These “not me” experiences are not nonexistent but areexpressed in indirect ways that can interfere with the con-duct of the individual’s life.9,10

As the social sciences adopted a cybernetic world-view, this theoretical perspective has been applied to devel-oping a concept of self. Glasersfeld12 spoke of the self as arelational entity that is given life through the continuity ofrelating. This relating provides the intuitive knowledge thatour experience is truly ours. It reflects the perspective ofknowing presented at the beginning of this section.

Watts13 describes what many authors feel is the self, asit can be understood through a cybernetic worldview. Self isthe whole, for it is part of the energy that is the universe andcannot be separated. “At this level of existence ‘I’ am imme-asurably old; my forms are infinite and their comings andgoings are simply the pulses or vibrations of a single andeternal flow of energy.” In this view, an individual is con-nected to every other living being in the universe. Thisplaces the self in a unique position of responsibility. The selfthen becomes responsible to everything because it is every-thing. This conceptual model resolves the issue of responsi-bility to society without relying on an individual self towhom responsibility is assigned.

Although the conceptual model represented here byWatts13 fits with current theoretical models being utilized innursing and the social sciences, it is not congruent with theexperience of most persons in Western society. This limitsits usefulness when working with clients in a clinical setting.It is presented here to provide practitioners with an alterna-tive model for themselves.

Stake14,15 developed an instrument to measure self-perception. Knowledge of the factors contributing to thedevelopment of the self-perception can assist in the formu-

lation of interventions focused on improving perceptions ofself. Five facets that contribute to a positive perception ofself emerged from Stake’s15 research: task accomplishment,power, giftedness, likeability, and morality. The characteris-tics of task accomplishment include perceptions of havinggood work habits and the ability to manage and completetasks efficiently. Perceptions of personal power include hav-ing strength, toughness, and the ability to influence others.Perceiving oneself as having special natural aptitudes andtalents provides the foundation for the facet of giftedness.Seeing oneself as pleasant and enjoyable to be with consti-tutes the characteristic of likeability. Morality is made up offactors that indicate the individual perceives himself or her-self as having qualities valued as good and virtuous.Additional facets have been added to these basic founda-tions.16,17 These factors include perceptions about physicalappearance, behavioral conduct and job, and athletic andscholastic competence.

Integration of theory and research related to self-concept indicates that positive self-perceptions evolve in apositive nurturing environment. Factors that contribute tothe success of this environment include positive support fordecision making; warm acceptance; positive, informativepraise; promotion of self-efficacy; a sense of belonging andpurpose; and the development of positive social skills.18

The complex interaction of facets that evolve intothe self-concept is an ongoing process occurring throughoutthe individual’s life. This process can be impacted bylife events, including illness,19,20 that impinge on any of theidentified factors, whether positively or negatively.

The Search Institute21 has developed, as a result oftheir research, a list of 40 assets that support the developmentof young people. If these assets are compared with the facetsnecessary to build a positive self-concept, many parallels canbe identified. The 40 assets are divided into internal andexternal. The four general external asset categories are sup-port, empowerment, boundaries and expectations, and con-structive use of time. The internal asset categories includecommitment to learning, positive values, social competen-cies, and positive identity. These eight general categories arefurther divided into assets that are more specific. The assetsof positive identity, empowerment, positive values, andsocial competencies are similar to the concepts of likeability,power, and morality discussed in the self-concept literature.

The Search Institute21 has found that the more assetsthe young person has, the fewer his or her high-risk behav-iors. Specific behaviors for nurturing the development ofeach asset have been identified. These asset developmentguidelines provide concrete direction facilitating the devel-opment of self-concept-enhancing experiences in the youngperson’s life. Specific asset-building behaviors are discussedin the next section under each developmental age to providepractitioners with direction in supporting the developmentof positive perceptions of self.

Sidney Jourard22 provides direction for interventionsrelated to an individual’s self-concept. The healthy self-


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concept allows individuals to play roles they have satisfac-torily played while gaining personal satisfaction from thisrole enactment. This person also continues to develop andmaintain a high level of physical wellness. This high level ofwellness is achieved by gaining knowledge of oneselfthrough a process of self-disclosure. Jourard22 states that, “Ifself-disclosure is one of the means by which healthy per-sonality is both achieved and maintained, we can also notethat such activities as loving, psychotherapy, counseling,teaching and nursing, all are impossible—without the dis-closure of the client.”

Elaboration of this thought reveals that for the nurse toeffectively meet the needs of the client, an understanding ofthe client’s self must be achieved. This understanding mustgo beyond the interpretation of overt behavior, which is anindirect method of understanding, and access the client’sunderstanding of self through the process of self-disclosure.

Dufault and Martocchio23 present a conceptual modelfor hope that also provides a useful perspective for nursingintervention. Hope is defined as multidimensional andprocess-oriented. Hopelessness is not the absence of hopebut is the product of an environment that does not activatethe process of hoping. Vaillot24 supports the view presentedby Dufault and Martocchio with the existential philosophi-cal perspective that hope arises from relationships and thebeliefs about these relationships. One believes that help cancome from the outside of oneself when all internal resourcesare exhausted. Hopelessness arises in an environment wherehope is not communicated. This model supports nursinginterventions from a systems theory perspective, because itvalidates the ever-interacting system, the whole. In this per-spective, the nurse, as well as the client, contributes to the“hopelessness,” and thus the responsibility of nurturing hopeis shared.23–27


INFANT

In general, the sources of anxiety begin in a very narrowscope with the infant and broaden out as he or she matures.Initially the relationship with the primary caregiver is thesource of gratification for the infant, and disruptions inthis relationship result in anxiety. As one matures, needs aremet from multiple sources, and therefore the sources of anx-iety expand. Specific developmental considerations are des-cribed in the paragraphs that follow.

The primary source of anxiety for the infant appearsto be a sense of “being left.” This response begins at about3 months. Sullivan,9 as indicated earlier, would contend thatthe infant could experience anxiety even earlier with anydisruption in having needs met by the primary caregiver. Atage 8 to 10 months, separation anxiety peaks for the firsttime. At 5 to 6 months, the infant begins to demonstratestranger anxiety. Primary symptoms include disruptions inphysiologic functioning and could include colic, sleep dis-

orders, failure to thrive syndrome, and constipation withearly toilet training. Stranger anxiety and separation anxietymay be demonstrated with screaming, attempting to with-draw, and refusing to cooperate. Both stranger anxiety andseparation anxiety are normal developmental responses, andshould not be considered pathologic as long as they are notsevere or prolonged, and if the parental response is appro-priately supportive of the infant’s needs.

Fear is a normal protective response to external threatsand will be present at all ages. It becomes dysfunctional atthe point that it is attached to situations that do not present athreat, or when it prevents the individual from respondingappropriately to a situation. Thus, it is important that chil-dren have certain fears to protect them from harm. The hotstove, for example, should produce a fear response to thedegree that it prevents the child from touching the stove andbeing injured. Fear is a learned response to situations, andchildren learn this response from their caregivers. Thus, itbecomes the caregivers’ responsibility to model and teachappropriate fear. If a mother cannot tolerate being left alonein the house at night with her children, her children willlearn to fear being in this situation. When this home islocated in a low-crime area with supportive neighbors andappropriate locks, fear becomes an inappropriate response,and the children may be affected by it for a lifetime.

Various developmental stages have characteristic fearsassociated with them. In the mind of the child, these charac-teristic fears present threats, so the fears can be seen bothas a source of fear and as a source of anxiety. The charac-teristic fears result from strong or noxious environmentalstimuli such as loud noises, bright lights, or sharp objectsagainst the skin. The response to fears produces physiologicsymptoms. The most immediate and obvious response of thechild is crying and pulling away from the stressful object orsituation.

Erickson28 indicated that he thought hope evolved outof the successful resolution of this first developmental stage,basic trust versus mistrust. Hope was perceived by Ericksonto be a basic human virtue. The type of environment that hasbeen identified as promoting the development of this basictrust is warm and loving, where there is respect and accept-ance for personal interests, ideas, needs, and talents.25

Several environmental conditions have been associated withearly childhood and are seen as increasing the perceptionsconsistent with hopelessness. These conditions are economicdeprivation, poor physical health, being raised in a brokenhome or a home where parents have a high degree of conflict,having a negative perception of parents, or having parentswho are not mentally healthy. From an existential perspec-tive, Lynch29 identified five areas of human existence that canproduce hopelessness. If these areas are not acknowledged inthe developmental process, the individual is at greater risk offrustration and hopelessness because hope is being intermin-gled with a known area of hopelessness. The five areas thatLynch identified are death, personal imperfections, imperfectemotional control, inability to trust all people, and personal


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areas of incompetence. This supports Erickson’s contentionthat hope evolves out of the first developmental stage,because these basic areas of hopelessness are issues relatedprimarily to the resolution of trust and mistrust. It should beremembered that previously resolved or unresolved develop-mental issues must be renegotiated throughout life.

Each developmental stage has a set of specific etiolo-gies and symptom clusters related to hopelessness. Becausethe relationship between self-concept strength and degree ofhopefulness is seen as a positive link, many of the etiologiesand symptoms of hopelessness at the various developmentalstages are similar to those of self-esteem disturbances.30

As conceptualized by Erickson,28 infancy is the pri-mary age for developing a hopeful attitude about life. If theinfant does not experience a situation in which trust inanother can be developed, then the base of hopelessness hasbegun. Thus, if the infant experiences frequent change incaregivers, or has a caregiver who does not meet the basicneeds in a consistent and warm manner, the infant willbecome hopeless. Research29 has indicated that childrenwho have been raised in an environment of despair areat greater risk for experiencing hopelessness. Symptomsof hopelessness in infants resemble infant depression or fail-ure to thrive. Because symptoms in infants are a generalresponse, the diagnosis of Hopelessness must be consideredequally with other diagnoses that produce similar symptomclusters, such as Powerlessness and Ineffective Coping.

One’s perceptions of place in the larger system and ofinfluence in this system begin at birth. These perceptions aredeveloped through interactions with those in the immediateenvironment and continue throughout life with each newinteraction in each new experience. Thus, the child learnsfrom primary caregivers that his or her expressions of needmay or may not have an effect on those around him or herand also learns what must be done to have an effect. If thecaregiver responds to the earliest cries of the infant, a senseof personal influence has begun. The two areas that consis-tently influence one’s perceptions of influence are disciplineand communication styles.

Implementation of discipline in a manner that pro-vides the child with a sense of control over the environmentwhile teaching appropriate behavior can produce a percep-tion of mutual system influence. Harsh, over-controllingmethods can produce the perception that the child does nothave any influence in the system if acting in a direct manner.This produces an indirect influencing style. An example ofindirect influence is the child who always becomes ill justbefore his parents leave for an evening on the town. The par-ents, out of concern for the child, decide to remain at homeand thus never have time together as a couple. Authoritarianstyles of interaction can also produce perceptions of power-lessness in adults in unfamiliar environments. If the hospitalstaff acts in an authoritarian manner, the client may developperceptions of powerlessness.

Double-bind communication can place the individualin a position of feeling that “no matter what action I take, it

appears to be wrong,” and also can produce a perceptionof powerlessness. They are “damned if they do and damnedif they don’t.” If the individual cannot influence this systemin a direct manner, again, indirect behavior patterns are cho-sen. Bateson30 proposes that this is the process behind thesymptom cluster identified as schizophrenia. This suggeststhat if the child is continually placed in the position ofbeing wrong no matter what he or she has done, the childcould develop the perception that his or her position is oneof powerlessness and carry this attitude with him or herthroughout life.

Infants have a need for consistent response to havingphysiologic needs met, and the most important relationshipbecomes that with the “parenting one.” If this relationship isdisrupted and needs are not met, symptoms related to infantdepression or failure to thrive could communicate a percep-tion related to powerlessness.

It is important to remember that self-concept, includ-ing body image, is developed throughout life. For the infant,the primary source of developing self-concept and bodyimage is physical interaction with the environment. Thisincludes both the environment’s response to physical needsand the body’s response to environmental stimuli.

Some behaviors that build assets in the infant and tod-dler include playing with the child at eye level; exposing thechild to positive values by modeling sharing and being niceto others; reading to the child; providing a safe, caring, stim-ulating environment; and communicating to the child that heor she is important by spending time with him or her.31

These behaviors have the strongest impact on theinfant when they are provided in an environment of consis-tent relationships and respect. Consideration of the child’spreferences and abilities nurtures positive self-knowledge.32


The basic sources of anxiety remain the same as for theinfant. Separation anxiety appears to peak again at 18 to 24months, and stranger anxiety peaks again at 12 to 18 months.Loss of significant others is the primary source of anxiety atthis age. In addition to the physiologic responses alreadymentioned, the child may demonstrate anxiety by motor rest-lessness and regressive behavior. The preschooler can beginto tolerate longer periods away from the parenting one andenjoys having the opportunity to test his or her new abilities.Lack of opportunity to practice independent skills canincrease the discomfort of this age group. Increased anxietycan be seen in regressive behavior, motor restlessness, andphysiologic response.

Sources of anxiety can include concerns about thebody and body mutilation, death, and loss of self-control.These concerns can be expressed in the ways previously dis-cussed, as well as with language and dramatic play, as lan-guage abilities increase. This could include playing outanxiety-producing situations with dolls or other toys. Thisplay can assume a very aggressive nature. The anxieties of


••••••


the day can also be expressed in dreams and result in night-mares or other sleep disturbance.

In this age group, fears evolve from real environmen-tal stimuli and from imagined situations. Typical fears ofspecific age groups are fear of sudden loud noise (2 years),fear of animals (3 to 4 years), fear of the dark (4 to 5 years),and fear of the dark and of being lost (6 years). Symptomsof fears include regressive behavior, physical and verbal cru-elty, restlessness, irritability, sleep disturbance, dramaticplay around issues related to the fear, and increased physicalcloseness to the caregiver.

Alterations to the body or its functioning place a childat this age at the greatest risk of experiencing hopelessness.If the child experiences a difference between self and otheror is ashamed about body functioning, in a nonsupportiveenvironment, hopelessness can develop. A specific issueencountered at this stage is toilet training. If the child isplaced in a position of being required to gain control overbowel and bladder functions before the ability to physicallymaster these functions has developed, the child can experi-ence hopelessness in that he or she truly cannot make his orher body function in the required manner. Peer interactionsare also important at this time because they foster the begin-nings of trust in someone other than the “mothering” one,thus understanding that hope can be gained elsewhere.

Struggle between self-control and control by othersbecomes the primary psychosocial issue. If appropriateexpansion of self-control is encouraged, the child willdevelop perceptions related to mutual systemic influence.This appropriate support is crucial if the child is to developa perception of a personal role in the social system. If thisstruggle for self-control is thwarted, the child can expressthemes of over control in play or become overly dependenton the primary caregiver and withdraw completely from newsituations and learning.

For the preschooler, there is a continuation and refine-ment of a sense of personal influence. Varying approachesare explored, and a greater sense of what can be achieved isdeveloped. One of the primary sources of anxiety during thisstage is loss of self-control. Symptoms of difficulties in thisarea include playing out situations with personal influenceas a theme and aggressive play.

Sources of the self-concept perceptions are theresponses of significant others to exploration of new physi-cal abilities and to the toddler’s place in these relationships.The primary concept of self is related to physical qualities,motor skills, sex type, and age. A concept of physical dif-ferences and of physical integrity is developed. Thus, situa-tions that threaten the toddler’s perception of physicalwholeness can pose a threat. This would include physicalinjury. Toilet training poses a potential threat to the success-ful development of a positive self-concept or body image.Failure at training could produce feelings of personalincompetence or of the body being shameful.

In the preschooler, physical qualities, motor skills, sextype, and age continue to be the primary components of self-

concept. Peers begin to assume greater importance in self-perceptions. Physical integrity continues to be important,and physical difference can have a profound effect on thepreschool child.

Actions that build assets in the preschooler includeplaying and talking to them on eye level; asking them to talkwith you about things they have seen; working with them touse words to express themselves; reading to them; takingthem to community events, museums, and cultural events;modeling for them how to behave; providing a supportivefamily life; providing clear rules and consequences; involv-ing child in creative activities; modeling expectation thatothers will do things well; valuing expressions of caring;assisting the child to learn the difference between truth andlying; assisting the child to make simple choices and deci-sions; and helping the child to learn how to deal nonvio-lently with challenges and frustrations.27 With growingsense of self independent of others, positive responses totheir increased competencies facilitates the development ofa positive perception of self.32

SCHOOL-AGE CHILD

Typically, fears are aroused by strange noises such as ghostsand imagined phantoms; natural elements such as fire,water, or thunder (6 years); not being liked or being late forschool (7 years); and personal failure or inadequacy (8 to 10years). Symptoms of these fears include physical symptomsof autonomic stimulation, increased verbalization, with-drawal, aggression, sleep disturbance, or needing to repeat aspecific task many times.

Concerns about imagined future events produce theanxieties of the school-age child. The specific concernvaries with the developmental age. Young school-agechildren demonstrate concerns related to the unknowns intheir environment, such as dark rooms, and natural ele-ments, such as fire or tornadoes. Older school-age chil-dren have anxieties related to personal inadequacies.Preadolescence brings increasing concerns about the valua-tion of peers and concerns about the acceptance of peers.Expression of anxiety can occur in the ways discussed in theprevious level, with the addition of increased verbalizationand compulsive behavior such as repeating a specific taskmany times.

Peers’ perceptions of the individual assume a role inthe development of attitudes related to personal hopefulnessand influence within the larger social system. This is built onthe perceptions achieved during earlier stages of develop-ment. The sense of a strong peer group can produce percep-tions of help coming from the outside as long as the childthinks and believes along with the group, but can produceperceptions of exaggerated personal influence. Problems atthis developmental stage can be demonstrated by with-drawal, daydreaming, increased verbalizations of helpless-ness and hopelessness, angry outbursts, aggressive behavior,irritability, and frustration.


••••••


Self-perception expands to include ethnic aware-ness, ambition, ideal self, ordinal position, and conscience.There is increasing awareness of self as different frompeers. Peers become increasingly important in developing aconcept of self, and there is increased comparison of realto ideal self.

Behaviors that can build assets in this age groupinclude exposing the child to caring environments and rolemodels outside the family; providing the child with useful,age-appropriate roles; providing clear and appropriateboundaries and expectations; promoting involvement in cre-ative activities; promoting involvement with positive learn-ing experiences; exposing the child to values that includecaring, honesty, and appropriate responsibility; and provid-ing the child opportunities to make age-appropriate deci-sions.31

ADOLESCENT

The developmental theme that elicits anxiety in this agegroup revolves around the development of a personalidentity. This is facilitated by peer relationships, which canalso be the source of anxiety. Expression of this anxietycan occur in any of the ways previously discussed and withaggressive behavior. This aggression can take both verbaland physical forms. A certain amount of “normal” anxietyis experienced as the adolescent moves from the family intothe adult world. Anxiety is considered abnormal only if itviolates societal norms and is severe or prolonged. Parentaleducation and support during this development crisis canbe crucial.

Peer relationships, independence, authority figures,and changing roles and relationships can contribute tofears for adolescents. Expression of these fears producescognitive and affective symptoms. These symptoms couldinclude difficulties with attention and concentration, poorjudgment, alterations in mood, and alterations in thoughtcontent.

The cognitive development of adolescents wouldsuggest that their perceptions of situations are guided byhypothetical–deductive thought, and as a result they coulddevelop reasonable models of hopefulness. This cognitiveprocess occurs in conjunction with a lack of a variety of lifeexperience and self-discipline and with a heightened state ofemotionality. This can result in a situation in which theimmediate goal can overshadow future consequences orpossibilities. An adolescent who appears very hopeful whencognitive functioning is not overwhelmed by emotions canbe filled with despair when involved in a very emotional sit-uation. Consideration of this ability is important when car-ing for this age group. It is important to distinguish problembehavior from normal behavior and mood swings. Kinds ofbehavior that could indicate problems in this area includewithdrawal and increased or amplified testing of limits.Situations that affect the peer group hope can place the ado-lescent at great risk.

Again, issues of dependence–independence assume aprimary role. The focus of this struggle is dependence onpeers and independence from family. The challenge for ado-lescents becomes achieving what Erickson and Kinney32

refer to as “affiliated individuation.” This requires that theylearn how to be dependent on support systems while main-taining their independence from these same support systemsand feeling accepted in both positions.

Body image becomes a crucial area of self-evaluationbecause of changing physical appearance and heightenedsexual awareness. This evaluation is based on the culturalideal as well as that of the peer group. Perceived personalfailures are often attributed to physical differences.

The importance of a positive self-concept for adoles-cents is highlighted by research that indicates a complexrelationship between self-concept, psychological adjust-ment, and behavior. Most significant is the consistent find-ing that low self-concept leads to a greater incidence ofdelinquency. This relationship appears to be strongestwith factors that are associated with the moral–ethical self-concept.33 Theoretical explanations for this phenomenonconsider the behavior as a method for balancing the negativeview of self or as part of a cycle of punishment resultingin shame, guilt, and expulsion rather than reconstruction.33

This link between self-concept and the complex of behav-iors termed delinquency increases the importance of provid-ing adolescents with asset-building experiences. Assetsimportant for adolescents include family love and support,parent involvement in schooling, positive family communi-cation, caring school environment, useful community roles,safe community environment, clear rules and consequences,positive adult role models, participation in creative activi-ties, involvement in community activities, spending mostevenings at home, positive learning experiences, develop-ment of planning and decision-making skills, develop-ment of interpersonal skills, development of a sense ofpersonal power, a sense of purpose, and a positive viewof the future.31 Specific asset-building behaviors can includeasking teens for their opinion or advice, helping teensto contribute to their communities, encouraging them toassume leadership roles in addressing issues that are ofconcern to them, talking with teens about their goals, pro-viding challenging learning opportunities, providingincreasing opportunities for teens to make their own deci-sions, celebrating their accomplishments, providing listen-ing time, learning their names, and asking them about theirinterests.34

ADULT

Changes in role and relationship patterns generate thefears specific to these age groups. These could includeparenthood, marriage, divorce, retirement, or death of aspouse. Fear expression in these age groups produces cogni-tive and affective symptoms similar to those described forthe adolescent.


••••••


A specific developmental crisis can produce a percep-tion of hopelessness and powerlessness. The situations thatplace the adult at risk are marriage, pregnancy, parenthood,and divorce.

Concerns about role performance assume an impor-tant role in self-perceptions. Perceived failures in meet-ing role expectations can produce negative self-evaluation.The number of roles a person has assumed and the personal,cultural, and support system value placed on the identifiedroles determine the threat that negative evaluation of per-formance can be to self-perception. Cultural value andpersonal identity formation determine the degree to whichbody image remains important in providing a positiveevaluation of self. The adult endows unique significanceto various body parts. This valuing process is personal andis often not in personal awareness until there is a threatto the part.

OLDER ADULT

As the older adult continues to age, he or she faces numer-ous challenges to self-perception and self-concept. Rolesmay change secondary to retirement or loss of significantothers, such as a spouse or child. Financial resources maybecome limited or fixed as a result of illness, retirement, orloss of spouse.35 Chronic illness that necessitates a decreasein social interactions or increased dependence on others, andthe resulting loss of control, has a negative impact on self-esteem for some elderly.36

Negative societal feedback, such as ageism, sends amessage to older adults that they are somehow no longervaluable to the society. In the face of these decrementallosses, it is necessary to consider what health-care profes-sionals can do to assist the older adult in maintaining a pos-itive regard for self.


••••••



Self-Perception andSelf-Concept Pattern

Anxiety

Body Image, Disturbed

Death Anxiety

Fear

Hopelessness

Anxiety ReductionCalming TechniqueCoping Enhancement

Body Image EnhancementCoping EnhancementSelf-Esteem Enhancement

Dying CareSpiritual Support

Anxiety ReductionCoping EnhancementSecurity Enhancement

Hope InstillationDecision-Making SupportEmotional SupportEnergy ManagementSupport System

Enhancement

Anxiety LevelAnxiety Self-ControlConcentrationCopingHyperactivity Level

Adaptation to PhysicalDisability

Body ImageChild Development:

AdolescenceSelf-Esteem

Acceptance: Health StatusAnxiety Self-ControlComfortable DeathDignified Life ClosureFear Self-ControlPsychosocial Adjustment:

Life ChangeSpiritual Health

Fear LevelFear Level: ChildFear Self-Control

Depression Self-ControlHopeMood EquilibriumPsychomotor EnergyQuality of LifeWill to Live(table continued on page 528)



••••••



Loneliness, Risk for

Personal Identity,Disturbed

Powerlessness, Risk forand Actual

Family Integrity PromotionSocialization EnhancementVisitation Facilitation

Decision-Making SupportSelf-Esteem Enhancement

ActualSelf-Esteem EnhancementSelf-Responsibility

Facilitation

Risk forSelf-Esteem EnhancementSelf-Responsibility

Facilitation


CommunicationFamily FunctioningFamily IntegrityFamily Social ClimateGrief ResolutionImmobility Consequences:

Psycho-CognitiveLeisure ParticipationLoneliness SeverityPsychosocial Adjustment:

Life ChangeRisk ControlRisk DetectionSocial Interaction SkillsSocial InvolvementSocial Support

Distorted Thought Self-Control Identity

Self-Mutilation Restraint

ActualFamily Participation in

Professional CareHealth BeliefsHealth Beliefs: Perceived

Ability to Perform;Perceived Control;Perceived Resources

HopeParticipation: Health Care

DecisionsPersonal AutonomySelf-Esteem

Risk forAbuse Recovery StatusAnxiety LevelAnxiety Self-ControlDecision-MakingDepression LevelDepression Self-ControlFear LevelFear Self-ControlHealth BeliefsHealth Beliefs: Perceived

Ability to Perform;Perceived Control;Perceived Resources

Immobility Consequences:Psycho-Cognitive

Information Processing



••••••


Self-Concept, Readinessfor Enhanced

Self-Esteem: ChronicLow, Situational Low,and Situational Low,Risk for

Self-Mutilation, Riskfor and Actual


Chronic LowSelf-Esteem Enhancement

Situational LowSelf-Esteem Enhancement

Situational Low, Risk forSelf-Esteem Enhancement

ActualBehavior Management-Self

HarmCounselingEnvironmental

Management SafetyImpulse Control TrainingWound Care

Participation in Health CareDecisions

Personal AutonomyRisk ControlRisk DetectionSelf-EsteemSocial Interaction SkillsSocial InvolvementSocial SupportStress Level

Abuse Recovery StatusBody ImagePersonal AutonomySelf-Esteem

Chronic LowDepression LevelPersonal AutonomyQuality of LifeSelf-EsteemSituational LowAdaptation to Physical

DisabilityGrief ResolutionPsychosocial Adjustment:

Life ChangeSelf-EsteemSituational Low, Risk forAbuse Recovery StatusAbuse Recovery:

Emotional; Financial;Physical; Sexual


Body ImageChild Development:

AdolescenceCopingGrief ResolutionNeglect RecoveryPsychosocial Adjustment:

Life ChangeRisk ControlRisk DetectionRole PerformanceSelf-Esteem

ActualIdentityImpulse Self-ControlSelf-Mutilation Restraint




ANXIETY

DEFINITION40

A vague uneasy feeling of discomfort or dread accompaniedby an autonomic response; the source is often nonspecific orunknown to the individual; a feeling of apprehension causedby anticipation of danger. It is an alerting signal that warnsof impending danger and enables the individual to takemeasures to deal with threat.


1. Behaviorala. Diminished productivityb. Scanning and vigilancec. Poor eye controld. Restlessnesse. Glancing aboutf. Extraneous movement (e.g., foot shuffling and hand

and arm movements)g. Expressed concerns due to change in life eventsh. Insomniai. Fidgeting

2. Affectivea. Regretfulb. Irritabilityc. Anguishd. Scarede. Jitteryf. Overexcitedg. Painful and persistent increased helplessnessh. Rattled

i. Uncertaintyj. Increased warinessk. Focus on selfl. Feelings of inadequacym. Fearfuln. Distressedo. Worried, apprehensivep. Anxious

3. Physiologica. Voice quiveringb. Increased respiration (sympathetic)c. Urinary urgency (parasympathetic)d. Increased pulse (sympathetic)e. Pupil dilation (sympathetic)f. Increased reflexes (sympathetic)g. Abdominal pain (parasympathetic)h. Sleep disturbance (parasympathetic)i. Tingling in extremities (parasympathetic)j. Increased tensionk. Cardiovascular excitation (sympathetic)l. Increased perspirationm. Facial tensionn. Anorexia (sympathetic)o. Heart pounding (sympathetic)p. Diarrhea (parasympathetic)q. Urinary hesitancy (parasympathetic)r. Fatigue (parasympathetic)s. Dry mouth (sympathetic)t. Weakness (sympathetic)u. Decreased pulse (parasympathetic)v. Facial flushing (sympathetic)w. Superficial vasoconstriction (sympathetic)x. Twitching (sympathetic)y. Decreased blood pressure (parasympathetic)


••••••



Risk forAnger Control AssistanceBehavior Management

Self-HarmEnvironmental

Management: Safety

Risk forAbuse Recovery StatusAbuse Recovery:

Emotional, Physical,Sexual

Anxiety LevelDistorted Thought Self-

ControlImpulse Self-ControlMood EquilibriumRisk ControlRisk DetectionSelf-Mutilation RestraintSubstance Addiction

Consequences


Anxiety 531

••••••

z. Nausea (parasympathetic)aa. Urinary urgency (parasympathetic)bb. Faintness (parasympathetic)cc. Respiratory difficulties (sympathetic)dd. Increased blood pressure (sympathetic)ee. Trembling/hand tremorsff. Shakiness

4. Cognitivea. Blocking of thoughtb. Confusionc. Preoccupationd. Forgetfulnesse. Ruminationf. Impaired attentiong. Decreased perceptual fieldh. Fear of unspecified consequencesi. Tendency to blame othersj. Difficulty concentratingk. Diminished ability to problem solve and learnl. Awareness of physiologic symptoms

RELATED FACTORS40

1. Exposure to toxins2. Unconscious conflict about essential values/goals

of life/Familial Association/heredity3. Unmet needs4. Interpersonal transmission/contagion5. Situational/Maturational crises6. Threat of death7. Threat to self-concept8. Stress9. Substance abuse

10. Threat or change in: role status, health status, interac-tion patterns, role function, environment, economicstatus.


1. Any hospital admission2. Failure to thrive3. Cancer or other terminal illnesses4. Crohn’s disease5. Impending surgery6. Hyperthyroidism7. Substance abuse8. Mental health disorders9. Actual, or threat of, significant life changing events

10. Perceptions of threat to self


FearFear is the response to an identified threat, whereasAnxiety is the response to threat that cannot be easilyidentified. Fear is probably the diagnosis that is mostoften confused with Anxiety. An example of a situation

in which Fear would be an appropriate diagnosis is:After being released from jail, the prisoner threatenedto kill the judge who placed him or her in jail. Thejudge, if experiencing psychological stress due to thisthreat and knowing the prisoner was out of jail, wouldreceive the diagnosis of Fear.

Disturbed Personal IdentityThis diagnosis is the most appropriate diagnosis if theindividual’s symptoms are related to a general distur-bance in the perception of self. Anxiety would be usedwhen the discomfort was related to other areas.

Dysfunctional GrievingThis would be considered an appropriate diagnosis ifthe loss was real, whereas the diagnosis of Anxietywould be used when the loss is a threat that is notnecessarily real, such as a perceived loss of esteemfrom others.

Ineffective Individual CopingThis would be the appropriate diagnosis if the individ-ual is not making the necessary adaptations to dealwith daily life. This may or may not occur with Anxietyas a companion diagnosis.

Spiritual DistressThis diagnosis occurs if the individual experiences athreat to his or her value or belief systems. This threatmay or may not produce Anxiety. If the primaryexpressed concerns are related to the individual’svalue or belief system, then the appropriate diagnosiswould be Spiritual Distress.

EXPECTED OUTCOME

Will verbalize a decrease in concern about current life situ-ation by [date].

Will demonstrate [number] alternativecoping strategy(s) by [date].

Will demonstrate absence of physiological signs andsymptoms of anxiety (note those that have been most signif-icant for this client) by [date].37

TARGET DATES

A target date of 3 days would be realistic to start evaluatingprogress. The sooner anxiety is reduced, the sooner otherproblems can be dealt with.


Anxiety is experienced at varying levels. The level of anxi-ety impacts the interventions selected. It is important for thenurse to assess anxiety level before selecting nursing inter-ventions.38

Low: Adaptive and can motivate for normal activities oflife

Mild: Prepares the person for action by sharpening thesenses, increasing the perceptual field, alertness, and


awareness. This level enhances learning and usually isnot perceived as stressful.

Moderate: Reduction of perceptual field, reduced alertnessto environment. Learning can occur at a reduced levelwith decreased attention span and ability to concentrate.Objective symptoms include increased restlessness, heartrate, respirations, perspiration, muscular tension, alteredspeech (rate, volume, pitch increased).

Severe: Perceptual field greatly diminished, focus ondetails or fixation on a single detail. Very limited atten-tion span and great difficulty with concentration or prob-lem-solving. Focus is on the self and desire to decrease

anxiety. Objective symptoms include Headaches, dizzi-ness, nausea, trembling, insomnia, palpitations, tachy-cardia, hyperventilation, urinary frequency, diarrhea.

Panic: Inability to focus on any details with mispercep-tions of the environment. Learning, concentration,and/or comprehension of simple directions cannot occur.Client experiences a sense of impending doom and/orterror. Objective symptoms include dilated pupils,labored breathing, severe trembling sleeplessness, palpi-tations, diaphoresis, pallor, muscular incoordination,immobility or purposeless hyperactivity, bizarre behav-ior, hallucinations, delusions.


••••••


Adult Health


Monitor anxiety behavior and relationship to activity,events, people, etc. every 2 hours on [odd/even] hour.

Give the patient an opportunity to verbalize perceptionof situation that is causing anxiety.

Monitor vital signs at least every 4 hours while awake at[times].

Reassure the patient that anxiety may be a normalresponse. Assist the patient to learn to recognize andidentify the signs and symptoms of anxiety (e.g.,hyperventilation, rapid heartbeat, sweaty palms, inabil-ity to concentrate, and restlessness).

Provide a calm, nonthreatening environment:• Explain all procedures and rationales for the procedure

in clear, concise, simple terms.• Decrease sensory input and distraction (e.g., lighting or

noise).• If the presence of family is calming, encourage signifi-

cant other(s) to stay with the patient

Attend to primary physical needs promptly.

Assist the patient to develop coping skills:• Review past coping behaviors and success or lack

of success.• Help identify and practice new coping strategies such

as progressive relaxation, guided imagery, rhythmicbreathing, balancing exercise and rest, appropriate foodand fluid intake (e.g., reduced caffeine intake), andusing distraction.

• Challenge unrealistic assumptions or goals.

• Place limits on maladaptive behavior (e.g., use of alco-hol or fighting).

When anxiety increases, the ability to follow instructionsor cooperate in the plan of care declines. Identificationof the behavior and causative factors enhances inter-vention plans.

Assists in determining the effects of anxiety. Helps deter-mine the pathologic effects of anxiety.

Helps identify the connection between the precipitatingcause and the anxiety experience.

Conveys calm and helps the patient focus on conversationor activity.

Conserves the patient’s energy, and allows the patient tofocus on coping with and reducing anxiety. Failure toattend to physical needs would increase anxiety.

Determines what has helped, and whether these measuresare still useful.

Methods that can be used successfully to decrease anxi-ety. Allows the patient to practice and become comfort-able with skills in a supportive environment.

Assists the patient to avoid placing extra stress on him-or herself.

Promotes use of appropriate techniques for reducinganxiety while avoiding harm to self and others.


Anxiety 533

••••••


Provide at least 20 to 30 minutes every 4 hours while thepatient is awake for focus on anxiety reduction. [Listtimes here.]

• Encourage the client to express feelings verbally andthrough activity.

• Answer questions truthfully.• Offer realistic reassurance and positive feedback.

Administer anti-anxiety medications as prescribed.Monitor and document effects of medication within30 minutes of administration.

Collaborate with the psychiatric nurse clinician regardingcare (see Mental Health nursing actions).

Refer the patient to, and collaborate with, appropriatecommunity resources.

Provides an opportunity to practice the technique andexpress anxiety-provoking experiences.

The effectiveness of medication is determined so modifi-cation can be provided if needed. Medication helpsreduce anxiety to a manageable level.

Collaboration helps provide holistic care. The specialistmay help discover underlying events for anxiety andassist in designing an alternate plan of care.

Support groups can provide ongoing assistance afterdischarge.

Child Health


Monitor for possible causes of anxiety to include situa-tion, recent event, trauma, or medications.

Review, with the child and parents, coping measures usedfor daily changes and crises.

Identify ways the parents can assist the child to cope withanxiety (e.g., set realistic explanations or demands, andavoid bribing or not telling the truth).

Adapt the routine to best help the child regain control(e.g., use of speech according to situation, and simplebut firm speech pattern).

Modify procedures, as possible, to help reduce anxiety(e.g., do not use intramuscular injection when an oralroute is possible).

*Exercise safe dosage administration of medications,especially amnesiacs and sedatives, with appropriateattention to back-up resuscitation equipment and staff.

Use the child’s developmental needs as a basis for care,especially for ventilation of anxiety (e.g., use of toys).

Allow the child and parents adequate time and opportuni-ties to handle required care issues and thus reduce anx-iety (e.g., when painful treatments must be done,prepare all involved according to an agreed-upon plan.

*Use a child life specialist when available to assist in pre-procedural planning.

Provides a realistic basis for plan of care.

The identification of coping strategies provides essentialinformation to deal with anxiety. Once they are identi-fied, the nurse can begin to evaluate the strategies thatare effective.

A major starting point is to describe the feelings andattempt to create a sense of control, which is morelikely in patients of a certain developmental capacity(e.g., those capable of abstract thinking). In youngerinfants, rocking can provide soothing repetitious notionwhen all other measures seem not to have calmed theinfant.

Allowing the child to plan for meals or snacks withchoices when possible or structuring the room to offera sense of self is conducive to empowerment.

Unnecessary pain or invasive procedures make over-whelming demands on the already stressed hospitalizedchild with anticipatory safety addressed.

The developmental level of the patient serves to guide thenurse in care. A holistic approach is more likely tomeet holistic health needs.

Appropriate time in preparation offers structure andallows focused attention, which empowers and helpsreduce anxiety as efforts are directed to what is known.




••••••


Child Health


Facilitate family involvement with care as appropriate,including feeding, comfort measures, and stories.

Offer sufficient opportunities for rest according to ageand sleep requirements.

Identify knowledge needs, and address these by havingthe family explain what they understand about treat-ments, procedures, needs, etc.

Point out and reinforce successes in conquering anxiety.

Assist the patient and family to apply coping in futurepotential anxiety-producing situations by presentingpossible scenarios that would call for utilization of thenew skills (e.g., reviewing use of new coping behaviorsbefore surgery).

Discuss with the client and family alternative methods forcoping with anxiety in the future.

Family involvement provides a sense of empowermentand growth in coping, thereby reducing anxiety andpromoting a sense of security in the child.

Proper attention to rest for each individual child will fos-ter coping capacities by conserving energy for coping.

Provides a teaching opportunity that increases thepatient’s and family’s knowledge about the situation,which assists in reducing anxiety.

Positive reinforcement that assists in learning.

Allows practice in a non-anxiety-producing environment.Increases skill in using coping strategy. Empowers thepatient and family.

Assists in an minimizing anxiety response to a moremanageable degree.

Women’s Health


Acute Anxiety AttackProvide a realistic, tranquil atmosphere (e.g., close door,

sit with the patient, remind the patient you are there tohelp).

• Do not leave the patient alone.• Speak softly using short, simple commands.• Be firm but kind.• Be prepared to make decisions for the patient.• Decrease external stimuli and provide a “safe” atmos-

phere.

Administer anti-anxiety medication as ordered, andmonitor effectiveness of medication within 30 minutesto 1 hour of administration.

Mild or Moderate AnxietyGuide the patient through problem-solving related to the

anxiety:• Assist the patient to verbalize and describe what she

thinks is going to happen.

Provides an atmosphere that assists in calming the patientand promotes the initiation of coping by the patient.

Medication is best taken in moderation and only underthe guidance of a physician. Today there are many nat-ural and herbal remedies on the market. While some ofthese therapies can minimize the side effects of strongmedications, they must be used with caution and guid-ance from those who understand and have utilizedthem in their practices. Practitioners of natural, alterna-tive, or complementary heath care are becoming morewell known in this country. Some of the terms used arealternative, complementary, natural, nonallopathic, andnon-Western medicine.41


Anxiety 535

••••••


• Describe to the patient what will happen (to the best ofyour ability), and compare with her expectations.

• Assist the patient in describing ways she can moreclearly express her needs.

Assist the patient in changing unrealistic expectations byexplaining procedures (e.g., labor process or sensationsduring a pelvic examination).

Encourage the patient to participate in assertiveness train-ing and/or to join an appropriate support group.41

Pregnancy and ChildbirthProvide the patient and significant others with factual

information about the physical and emotional changesexperienced during pregnancy.

Review the daily schedule with the patient and significantother. Assist them to identify lifestyle adjustments thatmay be needed for coping with pregnancy.

• Practicing relaxation techniques when stress begins tobuild

• Establishing a routine for relaxing after work• Developing a plan to provide frequent rest breaks

throughout the day (particularly in the last trimester)Refer to a support group (e.g., childbirth education

classes or maternal–child health (MCH) nurses in thecommunity).

Provide the patient and significant other with factualinformation about sexual changes during pregnancy:

• Answer questions promptly and factually.• Introduce them to people who have had similar experi-

ences.• Discuss fears about sexual changes.• Discuss aspects of sexuality and intercourse during

pregnancy:• Positions for intercourse during different stages of

pregnancy• Frequency of intercourse• Effect of intercourse on pregnancy or fetus

• Describe the healing process postpartum and timing ofresumption of intercourse.

Provide the patient support during the birthing process(e.g., Montrice, doula, or other support person orcoach).

Provide support for significant others(s) during thisprocess:

• Encourage verbalization of fears.• Answer questions factually.• Demonstrate equipment.• Explain procedures.

PostpartumProvide support for new parents during the first few days

of the postpartum period. Provide new parents withtelephone number to call with questions and concerns.Call new parents 36 to 48 hours after discharge:

By providing factual information, clarification of miscon-ceptions, and emotional support, it is possible toenhance the patient’s coping.42,43

Helps reduce anxiety about financial concerns due to hav-ing to quit work. Good planning and working with thepatient and partner to establish a realistic work sched-ule to present to the employer can assist the patient toreduce edema and fatigue and thus remain on the joblonger.

Factual information provides the family with the essentialknowledge needed in planning for the pregnancy,accomplishing the task of pregnancy, and adapting to anew infant.44

Assists in reducing anxiety. Increases coping.

Support of significant others leads to more support for thepatient.

Provides support and information from an “expert,”helping to reduce the anxiety of being new parents.




••••••


Women’s Health


• Formulate questions to receive simple one- or two-word answers.

• Allow new parents time to ask questions and voiceconcerns.

Before discharge from the hospital, give the newmother an appointment to return to follow-up clinic,or schedule home visit by nurse for herself and herinfant.

Assess the mother and baby for appropriate physicalrecovery from the birth:

• Maternal: episiotomy, cesarean section incision, breasts(lactating and nonlactating), involution of uterus, lochiaflow, fatigue level, etc.

• Infant: Number of wet diapers in 24-hour period, num-ber of stools in 24-hour period, color and consistencyof stools, feeding patterns, bilirubin check, follow-upon newborn screening and hearing screening as man-dated by most state law.

Discuss with the mother and partner, or family, the psy-chosocial aspects of being new parents. Be alert tocues or signs and symptoms of depression in themother. Pay special attention to any sleeping/eatingdisturbances, anxiety/insecurity, emotional labiality,mental confusion, loss of self, guilt/shame or suicidalthoughts, ignoring the infant’s cues, and actual neglectof the infant.45

Assist in developing and planning coping skills for newroles.

Provide appropriate education. (May have to repeat alleducation done during stay in hospital on postpartumunit.)

Monitor the infant and parents for attachment behaviors.

Refer the parents to appropriate resources for support andfurther follow-up:

• Lactation consultants• Primary care provider (obstetrician, pediatrician, certi-

fied nurse midwife, family practitioner, or nurse practi-tioner)

• Public health nurse• Visiting nursing services

Provide documentation of follow-up to the patient’sprimary care provider.

Provides a continuity of services and support and educa-tion for the new family during time between dischargeand follow-up visit to the primary health-care provider.

Check with your individual state as to the laws governingnewborn screening (comprehensive blood testing) andnewborn hearing screening.

Research has shown that postpartum depression can beginduring pregnancy, in the postpartum period, or in theweeks and months after the delivery of the baby. A par-ticularly vulnerable group are adolescents, with depres-sion rates as high as 47 percent.45–47

Readiness for learning for new mothers does not alwaysoccur during the hospital stay and requires follow-up.Research has shown that the most important learningneeds immediately postpartum were “stitches, epi-siotomy, and complications,” followed by feedingand illness.48,49


Anxiety 537

••••••


Midlife WomenProvide information about hormone influences on sleep

disorders, cardiac and mental functioning (forgetful-ness), lack of energy, irritability, weight gain, and per-ceptions of anxiety.50,51,53

Refer the client to appropriate resources for support andfurther follow-up:

• Physicians well versed in women’s health• Women’s health centers• Alternative health centers

• Menopause and midlife centers

Research has shown that hormone influences createsymptoms that many women report during the mid-lifecycle, usually beginning with perimenopause. Thehealth-care provider should address the concerns ofthese affective and cognitive disturbances in thesewomen and refer them to appropriate resources.50–54

Some resources are:National Women’s Health Network514 10th Street NW, Suite 400Washington, DC 20004(202) 347-1140http://www.Womenshealthnetwork.orgThe North American Menopause SocietyP.O. Box 94527Cleveland, Ohio 44101(440) 442-7550http://www.menopause.org

Mental Health


Approach the client in a calm, reassuring manner, assess-ing the caregiver’s level of anxiety and keeping this toa minimum.

Provide a quiet, nonstimulating environment that theclient perceives as safe. For the client experiencingsevere or panic anxiety, this may be a quiet room set-ting. This may include providing objects that symbol-ize safety to the client. (Note here the specialenvironmental adaptations necessary for this client.)

Provide frequent, brief interactions that assist the clientwith orientation. Verbal information should be pro-vided at a level that the client can process based on hisor her anxiety level. Note the client’s anxiety level, fre-quency, and focus of interactions here. (See AdditionalInformation for assistance in determining the client’sanxiety level.)

If the client is experiencing severe or panic anxiety, pro-vide support in a non-demanding atmosphere. [Noteclient-specific adaptations here.]

If the client is experiencing severe or panic anxiety, pro-vide a here-and-now focus.

• Provide the client with a simple repetitive activity untilanxiety decreases to the level at which learning canbegin. Note client specific activity here.

If the client is hyperventilating, guide in taking slow,deep breaths. If necessary, breathe along with theclient, and provide ongoing, positive verbal rein-forcement.

Anxiety is contagious and can be communicated from thesocial network to the client.55

Inappropriate levels of sensory stimuli can contribute tothe client’s sense of disorganization and confusion.38,55

Appropriate levels of sensory stimuli promote the client’ssense of control.28


High levels of anxiety decrease the client’s ability toprocess information.

High levels of anxiety decrease the client’s ability toproblem solve. Promotes the client’s sense of control.

Re-establishes a normal breathing pattern, and promotesthe client’s sense of control.




••••••


Mental Health


Provide a constant, one-to-one interaction for the clientexperiencing severe or panic anxiety. This should pre-clude use of physical restraints, which tend to increasethe client’s anxiety.

Provide the client with alternative outlets for physicaltension. Note techniques to be used by client here.These could include walking, running, talking with astaff member, using a punching bag, listening to music,doing a deep muscle relaxation sequence [number]times per day at [state specific times]. The outletshould be selected with the client’s input.

Discuss relaxation techniques with the client (visualimagery, deep muscle relaxation, massage, meditation,or music). Have the client select one activity he or shewould like to incorporate into his or her coping behav-iors. Schedule 30 minutes per day to practice thisactivity with the client. [Note here activity and practicetime.]

Sit with the client [number] times per day at [times] for[number] minutes to discuss feelings and complaints.As the client expresses these openly, the nurse can thenexplore the onset of the anxiety with the purpose ofidentifying the sources of the anxiety.

• After the source of the anxiety has been identified, thetime set aside can be utilized to assist the client indeveloping alternative coping styles.

Provide [number] times per day to discuss interests in theexternal environment with the client (especially withclients who tend to focus strongly on nonspecific phys-ical complaints).

Talk with the client about the advantages and disadvan-tages of the current condition. (Help the client to iden-tify secondary gain from the symptoms.) This wouldbe done in the individual discussion sessions or ingroup therapy when a trusting relationship has beendeveloped.

• During the interaction point out dysfunctional thinkingpatterns. These could include overgeneralization, mag-nification, dichotomous thinking, catastrophic thinking,and minimization

• When these thought patterns are identified (one of thefollowing responses can be implemented):• Discuss alternative ways of viewing the situation• Make a statement or ask a question that challenges

the perception• Examine the evidence for and against the thought

Presence of a calm, trusted individual can promote asense of control and calm in the client. Protects aclient’s right to the least restrictive environment.38

Promotes the client’s sense of control, and begins thedevelopment of alternative, more adaptive copingbehaviors.56

These techniques promote physiologic relaxation andshift the client to a state of parasympathetic nervoussystem recuperation.37 Repeated practice of a behaviorinternalizes and personalizes the behavior.56

Identification of precipitating factors is the first step indeveloping alternative coping behaviors and promotingthe client’s sense of control.56,57


Provides positive reinforcement through the nurse’s atten-tion for improved coping behaviors.38

Identification of contributing factors is the first step indeveloping alternative coping behaviors.56

Thoughts can influence feelings. Cognitive interventionshave been demonstrated to have a positive impact onthe long-term resolution of anxiety-related disor-ders.38,56

Alters distorted thought patterns.58


Anxiety 539

••••••


Provide the client with feedback on how his or her behav-ior affects others (this could be done in an individualor group situation). [The target behavior and goalsshould be listed here with appropriate informative posi-tive reinforcers.]

Provide positive specific informative feedback as appro-priate on changed behavior. (The target behavior andgoals should be listed here.) [Note positive feedback tobe used with this client here.]

Provide appropriate behavioral limits to control theexpression of aggression or anger. These limits shouldbe specific to the client and listed here on the care plan(e.g., the client will be asked to go to a private roomfor 15 minutes when he raises his voice to anotherclient). The client should be informed of these limits,and the limits should not exceed the client’s capability.The client should be informed of the time frame ofthe limits (e.g., the time limit for raising his voice is15 minutes). No limit should be set for an indefinitetime. All staff should be aware of the limits so they canbe enforced consistently with consistent consequences.

• Provide the client with an opportunity to discuss thesituation after the consequences have been met.

Interact with the client in social activities [number] timesper day for [number] minutes. This will provide theclient with staff time other than that which is used toset limits. The activities selected should be done withthe client’s input and stated here in the care plan.

Provide medication as ordered, and observe for appro-priate effects and side effects (these should belisted here).

Inform the client of community resources that provideassistance with crisis situations, and provide a tele-phone number before the client leaves the unit.

Develop a list of alternative coping strategies that theclient can use at home, and have the client practicethem before leaving the unit. (Note strategies to bepracticed and practice schedule here. This couldinclude role playing those situations the client identi-fies as the most difficult to manage.)

When signs of increasing anxiety are observed, talk theclient through one of the coping strategies they haveidentified. [Note here the client’s symptoms of anxietythat are to be addressed and the identified copingstrategy.]

Provide the client with a written list of appointments thathave been scheduled for outpatient follow-up.

Assists the client with consensual validation.Specific positive reinforcement encourages behavior and

enhances self-esteem.38

Positive feedback encourages behavior and enhances self-esteem.38,56

Client and milieu safety is of primary importance.38

Assists the client with an opportunity to review behav-ioral limits and provides the staff with an opportunityto communicate to the client that limit setting is not apunishment.

Promotes the development of a trusting relationship.Provides social reinforcers for pro-social behaviors.

Antidepressants are the most commonly prescribed andare supported as the primary pharmacological treat-ment for most anxiety disorders.38,56,59

Promotes the client’s sense of control and self-esteem.

Repeated practice of a behavior internalizes and personal-izes the behavior.55,59

Repeated practice of a behavior internalizes and personal-izes the behavior.

Provides visible documentation of the importance offollow-up. Increases the likelihood that appointmentswill be kept.




••••••


Gerontic Health



Monitor daily for side effects of anxiolytic medicationsagents if prescribed.

Assure consistent caregivers to the extent possible

Identify environmental factors that may increase anxiety,such as noise level, harsh lighting, and high trafficflow.

Provide direct, basic information on usual routines andprocedures.

The potential for side effects and drug interactions isincreased with older adults because of the decreasedmetabolism of drugs.

Decreases anxiety and facilitates trust.

The environmental factors mentioned, if not addressed,induce more stress in the older individual.

May help decrease autonomic nervous system activityand feelings of anxiety.

Home Health



Teach the client and family appropriate monitoring ofsigns and symptoms of anxiety:

• Increased pulse• Sleep disturbance• Fatigue• Restlessness• Increased respiratory rate• Inability to concentrate• Short attention span• Feeling of dread• Faintness• Forgetfulness

Involve the client and family in planning and implement-ing strategies to reduce and cope with anxiety:

• Family conference: Identification of sources of anxietyand interventions designed to decrease anxiety

• Mutual goal setting: Specific ways to decrease anxiety,and identification of role of each family member

• Communication


• Relaxation techniques (e.g., yoga, biofeedback, hypno-sis, breathing techniques, or imagery)

• Problem-solving techniques• Crisis intervention• Maintaining the treatment plan of health-care profes-

sionals who are guiding the therapy• Redirecting energy to meaningful or productive activi-

ties (e.g., active games and hobbies, walking, or sports)• Decreasing sensory stimulation

Provides baseline data for early recognition and inter-vention.

Family and client involvement enhances effectivenessof intervention.

Lifestyle changes require changes in behavior. Self-evaluation and support facilitate these changes.


Body Image, Disturbed 541

••••••


Assist the client and family to set criteria to help themdetermine when the intervention of a health-care pro-fessional is required (e.g., inability to perform activi-ties of daily living or threat to self or others).

Teach the client and family purposes, side effects, andproper administration techniques of medications.

Consult with or refer to assistive resources as indicated:• Caregiver support groups• Disease-specific support groups• Counseling services

Early identification of issues requiring professional evalu-ation will increase the probability of successful inter-ventions.

Provides necessary information for self-care.

Use of existing community services; provides for effec-tive utilization of resources.

BODY IMAGE, DISTURBED

DEFINITION40

Confusion in mental picture of one’s physical self.


1. Nonverbal response to actual or perceived change instructure and/or function

2. Verbalization of feelings that reflect an altered view ofone’s body in appearance, structure, or function

3. Verbalization of perceptions that reflect an alteredview of one’s body in appearance, structure, orfunction

4. Behaviors of avoidance, monitoring, or acknowledgmentof one’s body

5. Objectivea. Missing body partb. Trauma to nonfunctioning partc. Not touching body partd. Hiding or overexposing body part (intentional or

unintentional)e. Actual change in structure and/or functionf. Change in social involvementg. Change in ability to estimate spatial relationship of

body to environmenth. Not looking at body parti. Extension of body boundary to incorporate environ-

mental objects6. Subjective

a. Refusal to verify actual changeb. Preoccupation with change or lossc. Personalization of part or loss by named. Depersonalization of part or loss by impersonal pro-

nounse. Extension of body boundaries to incorporate environ-

mental objectsf. Negative feelings about body (e.g., feelings of help-

lessness, hopelessness, or powerlessness)g. Verbalization of changes in lifestyleh. Focus on past strength, function, or appearancei. Fear of rejection or of reaction by others

j. Emphasis on remaining strengths or heightenedachievement

k. Heightened achievement

RELATED FACTORS40

1. Psychosocial2. Biophysical3. Cognitive or perceptual4. Cultural or spiritual5. Developmental changes6. Illness7. Trauma or injury8. Surgery9. Illness treatment


1. Amputation2. Mastectomy3. Acne or other visible skin disorders4. Visible scarring from surgery or burns5. Obesity6. Anorexia nervosa


Situational Low Self-EsteemThis diagnosis addresses the lack of confidence inone’s self and is characterized by negative self-statements, lack of concern about personal appear-ance, and withdrawal from others not related to physi-cal problems or attributes. Disturbed Body Imagerelates to alterations in the perceptions of self due toactual or perceived alterations in body structure orfunction. The research indicates that for clients witheating disorders the focus of care should be on thetotal collection of self-schemas or identities; therefore,the preferred diagnosis would be Self-esteem,Chronic or Situational Low.60 The determination ofwhich of the Self-esteem diagnoses to implementdepends on the defining characteristics.





Disturbed Personal IdentityDisturbed Personal Identity is defined as the inabilityto distinguish between self and nonself. This diagno-sis is more involved in the mental health arena.Disturbed Body Image is a reaction to an actual orperceived change in the body structure or functionand incorporates the adult health area as well asmental health.

EXPECTED OUTCOME

Will verbalize at least [number] positive body image state-ments by [date].

Demonstrates [number] of strategies to enhance bodyimage or function by [date].

TARGET DATES

A target date of 3 to 5 days would be acceptable to use forinitial evaluation of progress.


••••••


Adult Health


Monitor for pain every 2 hours on (odd/even) hour.Administer analgesics. Monitor effectiveness of anal-gesic within 30 minutes of administration and use non-invasive techniques to keep pain under control.

Use anxiety-reducing techniques as often as needed.

Stay in frequent contact with the patient.

Be honest with the patient.

Point out and limit self-negation statements.

Do not support denial. Focus on reality and adaptation(not necessarily acceptance).

• Set limits on maladaptive behavior.

• Focus on realistic goals.

• Be aware of own nonverbal communication andbehavior.

Assist and encourage the patient to look at and useaffected body part during activities of daily living.

Teach the patient and significant others self-care require-ments.

Refer the patient to available resources:• Prosthetic devices• Assistive devices• Reconstructive and corrective surgery• Occupational therapy

Uncontrolled pain contributes significantly to problemswith body functioning, thus promoting the develop-ment and continuation of Disturbed Body Image.

Assists the patient in adapting to the changed bodyimage.

Promotes verbalization of feelings, and allows consistentintervention.

Any dishonesty in terms of recovery, return of function,or rehabilitation needs causes the patient to distrustcaregivers and promotes maintenance of body imagedisturbance.

Self-negating statements prolong the problem and inter-fere with rehabilitation potential.

The patient does not have to accept the problem, but heor she does have to, and can, adapt to the problem.

Maladaptive behavior supports the continuation ofDisturbed Body Image.

Supports continued progress. Allows positive feedbackfor achievement, and permits the patient to seeprogress.

Any avoidance behavior or nonverbal communication thatindicates dismay would support the patient’s idea ofhis or her unacceptability as a damaged person.

Helps the patient attend to altered body image construc-tively, and assists the patient to accept him- or herself.

Helps the patient adapt to body change, and improvesself-care management. Provides support for self-care,and assists significant others to adapt also.

Facilitates adaptation and decreases isolation. Provideslong-term support.



••••••


• Physical therapy• Rehabilitation services

Collaborate with the psychiatric nurse clinician regardingcare as needed. (See Mental Health nursing actions.)

Refer to and collaborate with community resources.

Collaboration promotes a holistic care plan and hastenssolving of the patient’s problem.

Provides long-term support. Cost-effective use of alreadyavailable support.

Child Health

According to age/developmental status, some components of Adult, Women’s, or Mental Health also apply, in addition tothe following:


Monitor for contributory factors for Disturbed BodyImage (e.g., disfigurement or perceived disfigurement)in addition to relationship issues. (The family may per-ceive such on behalf of the young infant or child.)

Utilize developmentally appropriate communication toassess and determine exact expression of DisturbedBody Image (e.g., use puppet play or constructive dia-logue with the toddler).

Provide factual information to assist in dealing withDisturbed Body Image (e.g., availability of assistivedevices or surgery).

Include other specialists, such as dietitian, occupational,physical, and speech therapist, and child life specialistas required.

Monitor, on a daily basis, for attitude toward body.

Refer patient and family to community support groups asappropriate. Note specific support group informationhere.

Provides database needed to plan interventions moreaccurately.

Developmental capacity has to guide the interaction togain accurate information.

Knowledge serves to reduce anxiety and assists thepatient to cope. Provides options to assist in decisionmaking.

Promotes a more accurate and developmentally appropri-ate holistic plan of care.

Allows daily evaluation, which promotes changes in planof care to best meet the patient’s current status.

Offers support by peers.

Women’s Health


Body Image: SurgeryAssist the patient to identify lifestyle adjustments that

may be needed (e.g., recuperation time or prosthesis asnecessary [mastectomy]).

Monitor the patient’s anxiety level and discuss preoper-atively:

• Discuss routines related to surgery (e.g., anesthesia,pain, length of surgery, postoperative care, andresources available to patient after discharge home).

Initiate discharge planning, and assist the health-careprovider and patient identify needed resources beforesurgery, allowing resources to be available to thepatient and family when needed.

l N O T E : In some instances, such as an infant or child with an anomaly or a condi-tion offering no hope of resolution, this alteration may accompany other disturbancessuch as self-esteem, parental coping, and loss.




••••••


Women’s Health


• Physical changes (e.g., cessation of menstruation ormenopausal symptoms related to surgical or naturalmenopause).

Allow the patient to grieve loss of body image (e.g., nolonger able to have children), and provide an empa-thetic atmosphere that will allow the patient to venti-late concerns about appearance or reaction ofsignificant other.

Dispel “old wives’ tales” (usually connected to hysterec-tomy) such as:

• You will no longer feel like a woman. (Reassure thepatient that although there will be no more pregnanciesor menstruation, hysterectomy does not affect sexualperformance, enjoyment, or response.)

• There will be masculinization. (There is no basis forthis belief.)

• There will be weight gain. (Weight gain will not occurif the patient participates in health living, including anexercise routine and proper diet.)

Involve significant others in discussion and problem-solving activities regarding life cycle changes thatmight affect self-esteem and interpersonal relationships(e.g., hot flashes, appearance, sexual relationships, orability to have children).

In collaboration with other health-care providers, providefactual information on hormone replacement therapy.

Body Image: PregnancyAssist the patient in identifying lifestyle adjustments due

to physiologic, physical, and emotional changes thatwill occur throughout pregnancy and postpartum.

Review with the patient the body changes that occur dur-ing pregnancy and the effect on body image (particu-larly for teenagers):

• Weight gain• Breast tenderness and enlargement• Enlargement of abdomen

Regardless of how menopause occurs, it is the signal oflife-cycle change and many women mourn the loss ofthe ability to bear children. Research has shown thatwhile many women morn the loss of reproductive abil-ities, other women begin to feel both liberated andoften begin to direct their energies toward the worldoutside of the home.50,51,53

Provides factual information, allowing the patient to askfurther questions and be realistic about her status andgoals.

Provides basic information, and allows early interventionfor anxiety. Provides an opportunity for teaching andclarification of misinformation.50,51,53

Assists the patient in making decision regarding use ornonuse of estrogen therapy. Recent research has shownthat some hormone replacement therapy does not sup-port cardiac health and can lead to dementia in olderwomen when not carefully watched. Many physiciansand compounding pharmacists are working together toprovide patients with individualized hormone replace-ment therapies, as well as natural sources ofhormones.41,50,51

Knowledge that body changes in pregnancy are normaland temporary encourages the patient to follow throughon care. Assists the patient to cope with the pregnancyand adapt to the changing images.



••••••


• Change in gait• Chlosama (mask of pregnancy)• Striations (stretch marks) from pregnancy

Consider the patient’s age and preparation for pregnancy,including (particularly for teenagers):

• Stress weight loss after delivery usually takes up to4 to 6 weeks.

• Discuss physical development.• Evaluate the patient’s attitude toward health-care

providers.• Discuss self-esteem.• Provide emotional support.• Prepare the patient for lifestyle interruptions.• Encourage the patient to bring an attractive, loose-

fitting dress to wear home.• Caution breastfeeding women against purposeful

weight loss while lactating.• Encourage non-breastfeeding mothers to follow low-

calorie, high-protein diet for weight loss.• Encourage exercise (begin slowly and work up to

desired plan).• Caution the patient to avoid fatigue.

Continued home care planning that encourages thepatient to better apply good health practices and thusincrease maternal and fetal well-being.

It is important that the new mother not resort to fad dietsto speed weight loss, especially if breastfeeding. Shewill lose the pregnancy weight by following a gooddiet and exercise program.

Mental Health


Spend [number] minutes with the client at [times] dis-cussing their perception of the situation. After a thera-peutic relationship has been established this discussioncan be expanded to include:

• Discuss with the client meaning of loss or change froma personal, religious and cultural perspective. This dis-cussion should also consider the impact of race, gender,and age.

• Discuss with the client the difference between thecultural ideal of physical appearance and the popu-lation norm based on the realities of physiology.This activity should be done by the primary carenurse who has developed a relationship with theclient.

• Discuss with the client his or her significant others’reaction to loss or change.

Set an appointment to discuss with the client and signifi-cant others effects of the loss or change on their rela-tionships. (Time and date of appointment and allfollow-up appointments should be listed here.)

Spend [number] minutes with the client each day to focuson values, thoughts, and feelings that perpetuate bodyimage problems. During this discussion:

Promotes the client’s sense of control, and provides infor-mation that can be utilized in developing a plan of carethat will fit within the client’s perception of self.Perceptions influence change.61

Expression of feelings in an accepting environment canfacilitate the client’s problem solving. Cognitive mapsinfluence the change process.61

Helps promote reality orientation by contrasting real withideal, and confronts irrational goals.

Support system understanding and support can facilitatethe client’s adjustment.

Expression of feelings and concerns in an accepting envi-ronment can facilitate problem solving. Social supportenhances coping.62,63

Cognitive maps influence behavior.64




••••••


Mental Health


• Point out dysfunctional thinking patterns. These couldinclude overgeneralization, magnification, dichotomousthinking, catastrophic thinking, and minimization

• When these thought patterns are identified (one of thefollowing responses can be implemented):• Discuss alternative ways of viewing the situation• Make a statement or ask a question that challenges

the perception• Examine the evidence for and against the thought

• Discrepancies between current behavior and clientgoals/values

• Have client explore perspectives for and against accept-ance of change

• Utilize goals established by client and credit client withany progress toward their goals

Spend [number] minutes each day to discuss assertivecommunication skills and practice these with the client.[Note specific behaviors to be practiced here.]

Schedule time with the client’s significant other to assesshis or her perception of the client and provide him orher with the necessary information to support theclient’s change. [Note here the time and person respon-sible for this meeting.]

Spend [number] minutes with the client at [times] toassist with efforts to enhance appearance.

Discuss with the client role exercise plays in health, anddevelop an appropriate exercise plan. [Note here theplan for this client.]

Provide physical activities two times per day at [times]that provide the client opportunities to define bound-aries of body. These activities should be ones the clientidentifies as enjoyable and that are easily accomplishedby the client. Those activities that are selected shouldbe listed here. If this diagnosis is in conjunction withan eating disorder, adjust exercise to appropriate levelsfor the client.

Have the client draw a picture of self before and afterbody change, and discuss this with him or her. Thisactivity can also be done with clay models constructedby the client. This activity should be done by the pri-mary care nurse who has developed a relationship withthe client.

When the client has begun to discuss issues related tobody change with the primary care nurse, the client canthen be asked to discuss reactions to image of self in amirror. One hour should be allowed for this activity.This activity should be done by the primary care nursewho has developed a relationship with the client.

Thoughts can influence feelings. Cognitive interventionshave been demonstrated to have a positive impact onthe long-term resolution of anxiety-related disor-ders.38,56 Alters distorted thought patterns.58

Client-centered interaction facilitates change.65

Assists in developing appropriate interpersonal bound-aries.66

Support assists with the development of lifestylechanges. Positive support has a positive impact onbody image.63 The support system’s response tochange can impact the client’s perception of self.62


Provides the client with the information necessary tomake healthy lifestyle choices. Exercise has a positiveimpact on self-esteem and assists with the client devel-oping comfort with changes.

Assists the client in developing a new perception of his orher body.

Assists the client in contrasting and externalizing his orher perceptions of self to facilitate development of con-gruence between real and ideal.

Facilitates the development of congruence between realand perceived self.



••••••


Discuss with the client the mental images held of whatthe altered body is like and what life will be like. Onehour should be allowed for this activity, and it shouldbe implemented by the primary care nurse after a rela-tionship has been established. Note the schedule forthis activity here.

Collaborate with physical and occupational therapy toschedule a time for client to attend group with othersexperiencing similar loss or change and that fit with theclient’s comparison targets. This could include supportgroups, activity groups, or specialty sports teams (e.g.,wheelchair basketball team). [Note group schedulehere.]

For clients with eating disorders evidence based practicesupports using a more comprehensive self-esteemintervention. (See Have You Selected the CorrectDiagnosis.) In addition, the following interventionsrelated specifically to body image can be considered:

• Monitor the client for suicidal thoughts or depressionrelated to weight gain.

• Have the eating disorder client draw a life-size pictureof self on paper hung on the wall; then have the clientstand against the picture and trace the real outline, anddiscuss the differences. This activity should be done bythe primary care nurse who has developed a relation-ship with the client.

Collaborate with social services to develop a dischargeplan that includes building community support for theclient and family.

Discussion of concerns in a safe environment facilitatesthe development of strategies of coping.

Group membership provides role models for life skillsnecessary for adaptation and the opportunity forupward comparison.60,63,67 In addition, groups instillhope, and enhance self-esteem.38,55,63

Disturbances related to perceptions of self are more com-prehensive than those related to body image, and effec-tive care addresses these broader concerns.60

Change in body shape can negatively impact self-esteemand increase feelings of depression.64

Assists the client in confronting the difference betweenhis or her perception of his or her body and the realbody size and shape.

Gerontic Health

The interventions for Adult Health can be applied to the aging client.

Home Health



Involve the client and family in planning and implement-ing strategies to reduce and cope with disturbance inbody image:

• Family conference: Discuss meaning of loss or changefrom family perspective and from the perspective ofindividual members. Discuss the effects of the loss onfamily relationship roles.

• Mutual goal setting: Establish realistic goals, and iden-tify specific activities for each family member (e.g.,assisting with activities as required or attending supportgroups as needed).

Family involvement enhances effectiveness of inter-ventions.



DEATH ANXIETY

DEFINITION40

The apprehension, worry, or fear related to death ordying.


1. Worrying about the impact of one’s own death onsignificant others

2. Powerlessness over issues related to dying3. Fear of loss of physical and/or mental abilities when

dying4. Deep sadness5. Fear of the process of dying6. Concerns of overworking the caregiver as terminal

illness incapacitates self7. Concern about meeting one’s creator or feeling doubt-

ful about the existence of a God or higher being8. Total loss of control over any aspect of one’s own

death9. Negative death images or unpleasant thoughts about

any event related to death or dying10. Fear of delayed demise11. Fear of premature death because it prevents the accom-

plishment of important life goals12. Worrying about being the cause of others’ grief or suf-

fering13. Fear of leaving family alone after death14. Fear of developing a terminal illness

15. Denial of one’s own mortality or impending death16. Anticipated pain related to dying

RELATED FACTORS40

To be developed.

RELATED CLINICAL CONCERNS1. Cancer2. Any hospital admission3. Impending surgery4. Cardiovascular diseases5. Serious symptoms related to unknown cause6. Autoimmune diseases7. Neurologic diseases8. Progressive chronic diseases


Anticipatory GrievingThis would be appropriate if the symptoms of grief arerelated to another’s death. If the symptoms are relatedto one’s own death, then the correct diagnosis wouldbe Death Anxiety.

AnxietyIf the symptoms are nonspecific or unknown to theindividual, then this would be the appropriate diagno-sis. Symptoms of anxiety that relate to one’s owndeath support the diagnosis Death Anxiety.


••••••


Adult Health


• Communication: Clarify responses to Disturbed BodyImage.


• Obtaining and providing accurate information regard-ing specific Disturbed Body Image and potential forrehabilitation.

• Maintaining safe environment.• Encouraging appropriate self-care without encouraging

dependence or expecting unrealistic independence.• Maintaining the treatment plan of the health-care pro-

fessionals guiding therapy.• Altering family roles as required.

Consult with, or refer to, assistive resources as indicated.• Support groups• Counseling services

Rehabilitation is a long-term process. Permanent changesin behavior and family roles require evaluation andsupport.

Utilization of existing services is efficient use ofresources. Rehabilitation therapists and support groupscan enhance the treatment plan.


EXPECTED OUTCOME

Will verbally express concerns about death by [date].Will identify [number] of strategies to manage anxiety

by [date].

TARGET DATESAny type of anxiety requires a sufficient amount of timeto deal with causes of the anxiety and to learn coping skills.A minimum of 7 days is appropriate before checking forprogress.

Death Anxiety 549

••••••


Adult Health


Take time to create a trusting relationship and a safeplace for the patient to talk about the things that makehim or her feel anxious about death.

Encourage patients to share their perception of the impli-cations of the illness for their life.68

Work with patient to identify potential sources of duressrelated to death (e.g., financial burdens, funeralarrangements, dysfunctional relationships etc.).

Respect the patient’s spirituality. Allow the patient toexpress his or her own beliefs about what his or herlife has meant, death, and after death.

Invite questions; answer honestly the questions that areasked; give reassurance where reassurance is possible,and emotional support to grieve when reassurance isnot possible.

• Listen when the patient describes his or her pain, andhelp ease both the physical and emotional pain.41

Give analgesics, anxiolytics, or antidepressant drugs asprescribed.

Direct patient to appropriate resources for assistance tomanage personal affairs if desired

Consult with chaplain or other spiritual support if desired.

A trusting relationship in which the patient feels freeto express his or her fears will assist the patient toopen up.

Promotes a trusting relationship, and encourages thepatient to seek and acknowledge the value of hisor her life.

Identification of these sources can assist in aligning thepatient with appropriate resources, thereby decreasinganxiety.

Promotes a trusting relationship.

Promotes a trusting relationship.

Child Health

l N O T E : Review developmental conceptual considerations with a keen appreciationof unique needs per each client plus, as applicable, those orders for Adult Health.


Assess for all possible contributing factors to include, asapplicable, the client’s verbalization of feelings, familyor caregiver perceptions, related family interactions orstressors, and risk indices, with attempt to identify anx-iety to be mild, moderate, or acute.

Once determined, provide appropriate factual informationto assist in how best to deal with anxiety.

Determine previous effective coping strategies.

A holistic assessment provides the most thorough data-base for individualized care.

There will be a difference in how mild, moderate, oracute anxiety is dealt with.

Successful coping strategies will assist in establishingpossible ways to augment current needs with modifica-tion to offer a sense of empowerment.




••••••


Child Health


Identify ways to assist the child in coping with appropri-ate incorporation of these strategies in daily care, withidentification of additional coping strategies.

Provide a calm atmosphere with limitation of excessivenoise, interruptions, or numbers of caregivers.

Provide all health-care team members updates, and seekinformation as needed to coordinate care on a dailybasis.

*Ideally the same primary care nurses ought to care forthis child and family during this time.

Facilitate appropriate involvement of all members of thehealth care team, especially the child life specialist,psychiatrist, or psychologist.

Provide anti-anxiety medications as appropriate toprovide adequate pain relief.

Provide opportunities for the child and family to sharethoughts of death-related anxiety issues or related feel-ings on an ongoing basis, with a sensitivity to unex-pected potential for same.

Provide developmentally appropriate tools to assistpatient with expression of feelings such as puppets,video viewing, art, or story telling. Note the items thatare most useful for this client here.

Provide opportunities for the utilization of family’s cul-tural practices. [Note special family needs here.]

Identify with the child and family ways to cope withdying and meaning of death.

Offer assistance in obtaining or notifying clergyman,counselors, or other supportive personnel as needed.

Provide reassurance according to personal family beliefsabout an afterlife or beliefs of same according to age-appropriate concerns of the child.

Feelings of empowerment will result when attempts aremade to adhere to a regimen that values previouslysuccessful coping strategies on which new strategiesmay then be more readily accepted.

Enhancement of coping is likely when the surroundingatmosphere does not add more stress.

The nurse is in the best position to offer coordination ofcare while maintaining continuity and affording trust.

Child specialists are most appropriately suited to assist inanxiety reduction strategies.

Provides augmentation of the therapeutic regimen andoffers relief from disturbing symptoms related to anxi-ety and pain.

Creating a sense of safe haven for all fears and thoughtsto be shared demonstrates a valuing of open communi-cation and the worth of the individual, thereby reduc-ing anxiety.

Age-appropriate expression of anxiety is fostered by pref-erences of the child per developmental capacity.

Individualized sensitivity to culture provides valuing ofthe person and the importance he or she places onfood, beliefs, or specific ways to cope.

When anxieties are diminished, actual engagement withdying can be realistically approached.

Anxiety may be further reduced with assistance fromthose who are experts in death and dying.

Anxiety may be further reduced when the child’s fears ofbeing alone or separated can be alleviated, while alsosupporting valued family beliefs.

Women’s Health

The interventions for this diagnosis in Women’s Health are the same as those given in Adult Health and Gerontic Health.

Mental Health


Provide a quiet, nonstimulating environment. (Note spe-cific adaptations to the environment that promote theclient’s relaxation, i.e., music, scents, lighting, etc.)[Note the behaviors that facilitate the development of arelationship with this client here.]

Inappropriate levels of sensory stimuli can contribute tothe client’s sense of anxiety.


Death Anxiety 551

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Spend [number] minutes per shift talking with the clientabout concerns and feelings. Include perceptions ofdeath and life.

Provide support necessary to meet identified client’s spir-itual needs. Note any special adaptations needed forthis support here (e.g., time for special prayers, medita-tion, reading, or contact with members of the client’sfaith community).58

After concerns are identified, validate and normalize theemotional response.

When concerns involve the family and/or support system,schedule [number] minutes each day to bring the fam-ily together and facilitate discussion of the issues andconcerns.

• Develop a list of issues that client/support system iden-tify as important.

• Explore beliefs/feelings that facilitate/hinder resolutionof concerns.

• Develop, with the client and support system, actionsthat are needed to resolve issues and concerns. Thiscould include resolution of past misunderstandings andforgiveness.

• During interactions with client and support systemmodel positive communication skills and facilitate pos-itive interactions between the client and support sys-tem.

Spend [number] minutes [number] times per day with theclient identifying alternative ways of responding toconcerns that decrease anxiety.

• Once a relationship has been established these discus-sions can also include opportunities for life review andmaking appropriate future plans. Note those topics tobe discussed with this client here.

Discuss with the support system their need to providecare, and provide them the necessary information andequipment to accomplish this at the level they feelcomfortable. (Note the assistance needed to accomplishthis care.)

Monitor the support system’s need for respite, andtalk with them about taking breaks to increase theirability to support the client. (Note the family’s needhere.)

Provide the client with information about his or hercare.

Assists the client in establishing the link between thefeelings of anxiety and thoughts, which facilitatesdevelopment of coping behaviors.70 An expression offeeling helps reduce intense emotion that can blockproblem solving.71 Frank discussion of fears and con-cerns can decrease anxiety.72

Validation of affect can decrease feelings of isolation andassist the client to connect with others, including thefamily.71

Assists the support system in bringing forth their ownresources and strengths to support one another andproblem solve. Decreases the feeling of isolation inmembers of the support system who are coping withthe impending death.71

Empowers the client and facilitates growth-promotingchange.71

Assists the client in identifying strengths and past copingmechanisms.72

Provides the support system with a sense of helpfulnessand control.71

Assists the family in coping with guilt about their need totake a break to enhance their coping resources.71

Empowers the client and decreases concerns about theunknown.




••••••


Mental Health


Spend [number] minutes [number] times each day assist-ing the client with a relaxation sequence he or she hasidentified as helpful. This could be deep muscle relax-ation, visual imagery, meditation, or deep breathingexercises. (Note the method identified by the clienthere.)

Provide massage for [number] minutes as needed toreduce anxiety. (Note the client’s preference for mas-sage here.)

Identify support systems in the community, and providethe client with a connection to these systems beforedischarge. (Note those identified for this client here.)

Shifts the physiologic state from sympathetic nervoussystem arousal to a state of parasympathetic recu-peration.73

Promotes physical and psychological relaxation.74

Provides visual documentation of the importance offollow-up and community support, increasing the like-lihood that these referrals will be utilized.

Gerontic Health

l N O T E : Research on the presence of death anxiety in older adults is slowly evolving,with no clear predictors of which older adults are at risk for experiencing death anxiety.Generally, elders with increased physical and psychological problems, and decreasedego integrity, are more likely to have death anxiety. Which physical and/or psychologi-cal problems have an impact on death anxiety are not yet clearly identified. In additionto selecting interventions from the adult health and mental health section, nurses caringfor older adults may find the following actions to be effective.75–77


Consult as needed with social services, mental health pro-fessionals, and/or religious counselors as signs of deathanxiety are noted.

Administer anxiolytics cautiously as needed.

Assist the client in completing advanced directives.

When consistent with the nurse’s personal values andbeliefs, pray with the patient as requested by thepatient.

Monitor older adults for signs of decreased ego integrity,such as statements of regret related to past life experi-ences, unresolved relational problems, and expressionsof despair.

Assist and encourage the older adult in life reviewprocess.

Refer the client to hospice services if the client meetsadmission criteria for hospice care.

Enables clients to discuss and address issues that may becontributing to distress.

Treatment of anxiety.

Death anxiety decreases in clients who have advanceddirectives.75

Prayer is an important source of coping with death anxi-ety in older clients.76

Decreased ego integrity is a contributor to death anxietynoted in older adults.

Provides an opportunity to review prior successes, effec-tive and ineffective coping strategies, personalstrengths, sense of life satisfaction, and psychologicalwell-being.

The hospice care team is prepared to address needs sur-rounding death and dying.

Home Health

In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the homehealth client.


Fear 553

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Manage the client’s pain and other troubling symptoms,such as nausea.

Encourage the family to become involved in the care ofthe client as much as they are able.

Help the client to talk about his or her anxiety and itssource.

Listen to client and family concerns, and answer all ques-tions truthfully. Tell the client and family as much asyou can about the dying process and disease process todecrease the number of “surprises” they may experi-ence with the dying process.77

Acknowledge all fears, feelings, and perceived threats asvalid to the client.

Reassure the client that even though the dying processcannot be stopped, someone will be with them andthey will not be left alone. Then ensure that a familymember or caregiver is with the patient at all times.

Administer anxiolytics as ordered, and educate the familyor caregivers about prescribed medications, theireffects, side effects, and scheduling.77

Physical symptoms often contribute to anxiety.

A sense of purpose and usefulness can replace anxiety.

Makes the client, the nurse, and the family more aware ofissues that need discussing or problems that need to beaddressed.

Understanding helps promote a sense of control andorder.

All client fears are valid to the client, whether they arerealistic or not.

Fear of abandonment is an almost universal fear of dyingpersons.77

Promotes a sense of well-being.

FEAR

DEFINITION40

Response to perceived threat that is consciously recognizedas danger.


1. Report of:a. Apprehensionb. Increased tensionc. Decreased self-assuranced. Excitemente. Scaredf. Jitterinessg. Dreadh. Alarmi. Terrorj. Panic

2. Cognitivea. Identifies object of fearb. Stimulus believed to be a threatc. Diminished productivity, problem solving ability,

learning ability3. Behaviors

a. Increased alertnessb. Avoidance or attack behaviorsc. Impulsivenessd. Narrowed focus on “it” (i.e., the focus of the fear)

4. Physiologica. Increased pulseb. Anorexiac. Nausead. Vomitinge. Diarrheaf. Muscle tightnessg. Fatigueh. Increased respiratory rate and shortness of breathi. Pallorj. Increased perspirationk. Increased systolic blood pressurel. Pupil dilationm. Dry mouth

RELATED FACTORS40

1. Natural or innate origin, for example, sudden noise,height, pain, or loss of physical support

2. Learned response, for example, conditioning or model-ing from or identification with others

3. Separation from support system in a potentially threaten-ing situation, for example, hospitalizations, or proce-dures

4. Unfamiliarity with environment experience(s)5. Language barriers6. Sensory impairment7. Phobic stimulus8. Innate releasers (neurotransmitters)



1. Any hospitalization2. Any threat to loss of a body part, loss of functioning, or

loss of life3. Perceived or Impending Death


AnxietyAnxiety is a vague uneasy feeling combined with anautonomic response to a source that is usually non-specific or unknown. Fear is the anxiety that is aresponse to recognized and realistic danger. Theresponse to meeting a bear in the woods or the antici-pation of this would be fear. A threat that cannot beidentified or linked to a specific situation would beanxiety.

Impaired ParentingThis diagnosis should be considered as the appropri-ate diagnosis when the child’s fears result from theparent’s modeling or reinforcing of a child’s fear orwhen the parent is not providing the appropriate sup-port for the developmental fears. An example mightbe the child who becomes uncontrollable in the cliniceach time an injection is indicated. During the assess-ment, the nurse discovers that, as a reinforcer to dis-

cipline at home, the parent tells the child that if he orshe does not behave, the nurse or doctor will give himor her a shot. In this situation, the parent’s inappropri-ate use of the threat of the injection produced a fearin the child.

Deficient KnowledgeIf the patient indicates that he or she is afraid of notbeing able to care for himself or herself, then the mostappropriate diagnosis would be Deficient Knowledge.Providing the patient with information, teaching, andreinforcement of self-care ability will overcome thisdiagnosis.

EXPECTED OUTCOMEWill be able to identify specific source of fear by [date].

Will demonstrate normalization of physiologicalsigns/symptoms [note specific signs to monitored for thisclient here] by [date].37

Will identify [number] of strategies for coping withfear by [date].

TARGET DATES

A target date of 2 to 3 days would be acceptable, because thesooner the fear can be reduced, the sooner other problemscan be resolved.


••••••


Adult Health


Establish a therapeutic and trusting relationship with thepatient and family by actively listening, being nonjudg-mental, sitting with the patient, etc.

Identify other primary nursing needs, and deal with theseas needed.

Provide explanations and appropriate teaching for proce-dures, diagnosis, treatments, and prognosis.

Involve the patient in developing attainable goals andplan of care.

Assist the patient to identify positive aspects of the situa-tion

Support the patent’s efforts at objectively describing feel-ings of hopelessness

Assist the patient to find alternatives to feelings of hope-lessness.

Hopelessness may prompt unhealthy eating patterns.(See nursing care plans related to ImbalancedNutrition and/or Fluid Balance.)

Promotes an environment that encourages the patientand/or family to verbalize concerns. Promotes anempathetic environment.

Attention to basic needs may decrease feelings of hope-lessness and of being of no value.

Allows the patient to validate reality.

Validates reality and encourages use of alternate copingtechniques.


Fear 555

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Support active participation in activities of daily living.Allow for preferences in day-to-day decisions (e.g.,establishing a bath time).

Refer to psychiatric nurse clinician as needed. (See Mental Health nursing actions.)

Identify religious, cultural, or community support groupsprior to discharge. Provide appointments for follow-up.

Helps restore sense of being in control.

Collaboration promotes a more holistic and completeplan of care.

Support groups can provide advocacy for the patient andcontinued monitoring and support of the patient afterdischarge from the hospital.

Child Health

Depending on gender and age/developmental status, some content of Adult, Women’s, and Mental Health may also apply.


Offer brief interactions that assist the patient and familywith orientation (e.g., hospital unit, procedures, andaspects of care).

In instances of severe fear:• Provide support in a nondemanding atmosphere.• Provide a here-and-now focus.• Provide one-to-one care.• Offer simple, direct, repetitive tasks.

Provide the patient and family with ways to assist andalternative outlets for physical tension. These outletsshould be stated specifically and could include walk-ing, talking, etc., at least [number] times per day at[times]. These outlets should be designed with inputfrom the patient.

Sit with the patient and parents [number] times per day at[times] for [number] minutes to discuss feelings andcomplaints.

*The same primary care nurses would ideally participatein this process.

Monitor patient and parents to for changes in feelingsabout fears. Discuss these changes with the patient andparents.

Provide appropriate behavioral limits to control theexpression of aggression or anger. These limits shouldbe specific in time, expected behavior, and conse-quences. Note the plan for this client here.

Provide the patient and parents with opportunities to dis-cuss the behavior after consequences have been met.

Provide opportunities for socialization appropriate for thepatient and family. Note patient and family preferenceshere.

Brief explanations and factual information serve toempower the patient and family as the unknown ismade known. The patient and family can then focuson dealing with the identified fear rather than withadded fears.

Avoids overwhelming the patient. Promotes a senseof trust.

Providing such outlets promotes release of tension.

As the patient or parents express these factors openly, thenurse can explore the possible onset of fear with thepurpose of individualizing the plan according to thepatient’s needs. The subjective verbalization of fearshelps reduce the preoccupation of the patient with thefear in the trusting relationship of nurse–patient/family.

Reflection on an ongoing basis demonstrates a sensitivityto need.

Structured rules regarding behavioral consequences createa sense of limits, which provides security for the child.

Rediscussion and clarification of events serves to updateneeds and provides feedback for evaluation. Valuingof the patient is also shown.

Socialization is vital as the individual or family assumescoping behaviors and learns new coping skills.




••••••


Child Health


Develop a list of alternative coping strategies to be prac-ticed by the patient and family before dismissal (e.g.,communication or progressive relaxation). Note tech-niques to be used by patient here.

Ensure follow-up appointments by scheduling them forthe patient before dismissal.

Assist the patient and family to view situation representedas something that can be managed. Model positivereinforcement of desired behavior patterns.

Consult with child mental health specialists for unre-solved issues related to fear. Make necessary referralsas appropriate.

Allows practice in a nonthreatening environment.Increases skills.

Follow-up appointments help ensure follow-up care.

Validation of success in coping provides a sense ofempowerment.

Provides appropriate anticipatory guidance and offers agreater likelihood of resolution or coping with fears.

Women’s Health

l N O T E : Phobias affect approximately 2 to 3 percent of the adult population, and 80percent of the affected group are female. The most common phobias among women areagoraphobia, fear of animals, and fear of social situations.78,79


Obtain a detailed history of the patient’s fears:• Encourage the patient to discuss signs and symptoms

or precipitating event.• Ascertain how often problem occurs.• Have the patient describe her reaction.• Identify coping mechanisms that have previously

helped.• Identify those factors or coping mechanisms that do not

help.

Domestic ViolenceProvide a nonjudgmental, safe environment for all

women patients to verbalize their fears. Obtain a goodhistory that can identify high-risk families and high-risk situations. Be alert to subtle clues in the patient’shistory or physical examination that hint at physicalabuse.

Patiently explain all procedures and their purpose to thepatient before performing them. Be aware that proce-dures in labor and delivery can trigger unpleasant fearsand anxieties in the patient, with possible flashbacks toan abusive situation or rape. Perform necessary proce-dures as quickly as possible and with empathy, allow-ing the patient to direct as much of the care aspossible. Encourage the patient to verbalize her fearsand verbally relive the birth experience in a nonjudg-mental environment.

Provides an essential database for planning appropriateinterventions.

Domestic violence against women cuts across all socioe-conomic, age, religious, and ethnic strata of the popu-lation. Physical abuse usually concerns control andpower issues. Domestic violence is not necessarilyphysical; it refers to violence in any form, both physi-cal and verbal.51,80–84

Be sensitive to cultural norms in dealing with pregnantwomen. It is important to be able to speak the patient’slanguage if the health-care provider is to establish theneeded rapport to care for the patient. Often immigrantwomen suffer more severe and repeated abuse beforethey are aware that they are being abused.84 Womenoften delay care during pregnancy because of an abu-sive situation.83


Fear 557

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Screen for abuse at every opportunity, during the hospitalstay and on postpartum follow-up visits.80–83

Educate women about resources available to themand how you, the health-care provider, can assistthem.80,83

Provide written educational material.

Inform patients of services and shelters for the batteredwoman. Post telephone numbers in conspicuous places.Post telephone numbers in the women’s bathroom(unavailable to men, so they cannot see the partner get-ting the number). Tell women to memorize the numberand never write it down.

Birthing ProcessProvide a comfortable, nonjudging atmosphere to encour-

age the patient and her significant other to verbalizetheir fears of:

• The unknown• Safety for herself and her baby• Pain during the birthing process• Mutilation during the birthing process• “Losing control” during the birthing process

Refer the patient to appropriate support groups for infor-mation:

• Childbirth education classes in the community• Special national organizations

Monitor the patient’s level of confidence using preparedchildbirth techniques during labor:

• Encourage use of relaxation and prepared childbirthtechniques during labor.

• Provide ongoing and accurate information, during thelabor and birth process, to both the patient and her sig-nificant other.

• Assist the patient in using “imagery” to overcome fearsduring the birthing process.

Provide continuity of care by remaining with and provid-ing comfort for the laboring woman throughout thebirthing process:

• Provide clear answers to the patient’s questions.• Keep the patient informed of her progress in the

birthing process.

Provide the patient and significant others with as manyopportunities as possible to make decisions about hercare during the birthing process.

Although this material can be displayed in waiting roomsand public areas, it is best to duplicate the display inbathrooms where only the woman can go. Resourcesand “help lines” need to be on small cards that can beconcealed easily by the woman.80–83

It is important to provide information about resources tothese women in an unobtrusive manner, so they canaccess the resources when they are ready.

Assists in decreasing fear through promotion of verbal-ization.

Provides effective use of existing resources and long-range support.

Use of relaxation techniques and provision of informationregarding progress facilitate the labor process by eas-ing anxiety and promoting comfort.44

Encourages involvement in the process, which enhancescoping.




••••••


Mental Health


Provide a quiet, nonstimulating environment for theclient. This would include removing persons andobjects that the person perceives as threatening. If theperson is experiencing a thought disorder with delu-sions and hallucinations, attention should be paid tothe details of the environment that could be misinter-preted. At times a same-sex caregiver can increase fearin the client.

Obtain the client’s understanding of the threat. Use sim-ple concrete questions to obtain information (e.g.,“What do you need right now?”)

Provide a one-to-one relationship for the client with amember of the nursing staff. This should be maintaineduntil the symptoms return to normal levels. Remainwith the client in unfamiliar situations.

Provide clear answers to the client’s questions.

Carry on conversations in the client’s presence or visionin a voice that the client can hear.

Inform the client of plans related to care before the plansare implemented. If possible, discuss these with theclient (e.g., if it is necessary to move the client toanother room or institution, the client should beinformed of this change before it takes place).

Orient the client to the environment.

Maintain a consistent environment and routine. Recordthe client’s daily routine here, along with notes aboutclient’s special reactions to visitors and staff members.

Provide a primary care nurse for the client on each shift.

Sit with the client [number] minutes [number] times pershift. (Initially the times should reflect short, frequentcontact. This can change with the client’s needs.)

Provide the client with objects in the environment thatpromote security. These may be symbolic items fromhome or religious objects. List significant items here.

Note the client’s desired personal space, and respect theselimits (the general guidelines should be stated here).

Assist the client with sorting out the fearful situation by:• Recognizing that the experience is real for the client

even though it may not be your experience of the situa-tion: “I can see that you are very upset. I can under-stand how those thoughts could make you fearful.”

Inappropriate levels of environmental stimuli can increasedisorientation and confusion. Manipulation of the envi-ronment can eliminate the fear response.43

Facilitates the development of interventions that directlyaddress the client’s concerns. High levels of anxietydecrease the client’s ability to process complexinformation.38

Promotes a trusting relationship, and enhances the client’sself-esteem. After the relationship is developed, pro-vides a sense of security in unfamiliar situations

Inappropriate amounts of sensory stimuli can increase theclient’s confusion and disorganization.

Meets safety needs of the client by eliminating stimulithat could be misinterpreted in a personalized manner.

Promotes the client’s sense of control and enhances self-esteem.

Promotes safety needs by increasing the client’s familiar-ity with the environment in the accompaniment of atrusted individual.

Promotes the client’s sense of safety and trust by main-taining consistency in the environment.

Promotes the development of a trusting relationship.

Promotes the development of a trusting relationship.Interaction with the nurse can provide positive rein-forcement and enhance self-esteem.

Meets the need for affiliation by providing meaningfulobjects to which the client is attached.43

Communicates respect for the client, while decreasing theclient’s anxiety by maintaining a comfortable personalspace.

Communicates respect for the client, while encouragingreality testing.


Fear 559

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• Providing feedback about distorted thoughts: “No, I amnot going to punish you. I am here to talk with youabout your concerns.”

• Talking about client’s perceptions specific terms andnot vague generalizations: “When you say your familyis out to get you, who and what do you mean?”

• Focusing conversations on the here and now; thisincludes information about the effects of the client’sbehavior on those around him or her, your experienceof the client, and your perceptions of the environment.

• Not arguing about the client’s perceptions; instead, pro-vide feedback in the here and now with your percep-tions of the situation. The client tells you that you mustbe angry with him or her because of the look you hadon your face while reviewing the client’s chart. Yourresponse is, “I am not angry with you, when I waslooking at your chart, I was thinking about the conver-sation we had this morning about your job.”

Provide the client with as many opportunities as possibleto make decisions about his or her care and the currentsituation.

Develop, with the client, a list of potential solutions tothe threatening situation.

Review the developed list of solutions with the client, andassist him or her in evaluating the benefits and costs ofeach solution.

Rehearse with the client, if necessary, the solutionselected, or have the client practice a new response tothe threatening situation. Note times and frequency ofthis practice here.

Provide positive informative verbal feedback to the clientabout efforts to resolve the threatening situation.

Spend [number] minutes [number] times each day withthe client to develop alternative outlets for the feelingsgenerated by the threatening situation, and provide theopportunity for the use of these outlets. These wouldbe noted in the written care plan so other staff mem-bers would be aware of them and could talk the clientthrough their use when they notice the client’s discom-fort increasing.

Provide the client feedback that identifies early behav-ioral cues indicating fear or that he or she is entering afearful situation.

Support the client in using alternative coping strategiesdeveloped by:

• Providing the necessary environment• Providing the appropriate equipment• Spending time with the client doing the activity• Providing positive reinforcement for the use of the

strategy (this could be verbal as well as with specialprivileges) [Note the special adaptations needed here.]

Promotes the client’s sense of control, and enhancesself-esteem.

Teaches the client problem-solving skills, while promot-ing the client’s sense of control and strengths.

Facilitates the client’s decision-making process.

Behavioral rehearsal helps facilitate the client’s learningnew skills through the use of feedback and modelingby the nurse.43

Positive feedback encourages behavior and enhances self-esteem.43

Planned coping strategies facilitate the enactment of newbehaviors when the client is experiencing stress.

Early recognition and intervention enhances the opportu-nities for new coping behaviors to be effective.

Promotes the client’s perception of control. Positive rein-forcement encourages behavior.




••••••


Mental Health


If fear is related to a specific object or situation, teach theclient to use deep muscle relaxation, and then teachthis along with progressively real mental images ofthe threatening situation. This is for those situationsthat will not cause the client harm if he or she isapproached, such as riding in elevators. This couldalso include other methods of relaxation such asmusic, deep breathing, thought stopping, fantasy,assertiveness training, audiotapes with relaxationimages or sequences, yoga, hypnosis, andmeditation.

Note techniques to be taught with teaching schedule here.

Explore with the client ways to increase the feeling ofcontrol in threatening situations; e.g., a fear of eleva-tors could be altered by the client only riding in eleva-tors with emergency telephones and only riding whenhe or she could stand near the telephone. The fear mayalso indicate that the client is feeling out of control inan unrelated area of his or her life. If this is suspected,this should be explored and ways of increasing controlshould be explored (e.g., a woman’s fear of drivingcould indicate that she feels out of control in her mar-riage, and increased assertive behavior with her hus-band removes the fear). [Note schedule for thisdiscussion here.]

When the client shows signs and symptoms of fear (notethose signs and symptoms unique to this client here),talk him or her through the coping and/or relaxationstrategies that have been identified as useful to him orher. Note the client’s specific coping strategies to beused here. This may include removing the client fromthe fear-producing context.

Provide positive reinforcement for the client’s implemen-tation of the new coping behaviors. Note those thingsthat are to be used to reinforce this client here.

If the method to increase control involves interactionswith the health-care team, these should be noted inspecific terms on the client’s chart.

Assist the client in developing strategies to be used inthe community after discharge, and role-play varioussituations with the client [number] times for [number]minutes.

Collaborate with other members of the health-care teamto provide clients with pharmacologic agents to beadministered before exposure to a context that elicitsfear. Monitor for side effects of these medications andprovide appropriate client education.

The relaxation response inhibits the activation of theautonomic nervous system’s fight-or-flight response.

Shifts physiologic state from sympathetic nervous systemarousal to a state of parasympathetic recuperation.73

Behavioral rehearsal helps facilitate mastery of newbehavior through the use of feedback and modeling bythe nurse.43 Promotes a sense of control.70 Contextualstimuli can elicit the fear response.43

Positive reinforcement encourages behavior.


Behavioral rehearsal provides opportunities for feedbackand modeling from the nurse.

Gamma-aminobutyric acid (GABA) agonists inhibit theamygdala, which is the location of the fear response.43


Fear 561

••••••

Gerontic Health

In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the agingclient.


Assist the patient in discussing the source of fear (e.g.,pain, death, or loss of function) by scheduling at least30 minutes twice a day at [times] to confer with thepatient about the fear.

During the interview, observe behaviors of the patient.Patients will not readily offer information of abuse.You may observe:

• The patient is unable to provide information withoutthe caregiver present.87

• The caregiver demonstrates aggressive behavior towardpatient.87

• The patient seems to be controlled by the caregiver andthe caregiver shows no affection or seems indifferent tosituation.87

Identify which coping strategies that the client has previ-ously used have been effective and which have not.Discuss ways that effective strategies can be used tocope with future fearful events.

Assist the patient in determining what resources are avail-able to enhance his or her coping skills.

Addressing the source of fear enables the patient todevelop a specific plan of action to reduce the fear.

Elder abuse is not new, but it receives little attention asthe elderly in this country seem to be “the invisiblepopulation.”87

This helps the client identify effective strategies whilereinforcing that he or she can cope with his or her fear.

Knowledge and use of appropriate resources aid in reduc-ing fear-provoking experiences by increasing thepatient’s inventory of skills to deal with fear.

Home Health



Ask the client to describe the precipitating event.

Determine the client’s perception of the fear.

Assess sources of support, resources, and usual copingmethods.

Identify which coping strategies that the client has previ-ously used have been effective and which have not.Discuss ways that effective strategies can be used tocope with future fearful events.

Help the client to talk about his or her fear and its source.

Listen to the client’s and family’s concerns, and answerall questions truthfully. Tell the client and family asmuch as you can to decrease the number of “surprises”they may experience with the fear-producing event.

Assists the nurse in understanding the client’s perceptionof the fear.



This helps the client identify effective strategies whilereinforcing that he or she can cope with his or her fear.

Makes the client, the nurse, and the family more aware ofissues that need discussing or problems that need to beaddressed.

Understanding helps promote a sense of control andorder.



HOPELESSNESS

DEFINITION40

A subjective state in which an individual sees limited or noalternatives or personal choices available and is unable tomobilize energy on own behalf.33


1. Passivity, or decreased verbalization2. Decreased affect3. Verbal cues (despondent content, “I can’t,” sighing)4. Closing eyes5. Decreased appetite6. Decreased response to stimuli7. Increased or decreased sleep8. Lack of initiative9. Lack of involvement in care or passivity allowing care

10. Shrugging in response to speaker11. Turning away from speaker

RELATED FACTORS40

1. Abandonment2. Prolonged activity restriction creating isolation3. Lost belief in transcendent values/God4. Long-term stress5. Failing or deteriorating physiologic condition


1. Any disease of a chronic nature2. Any disease with a terminal diagnosis3. Any condition where a diagnosis cannot be definitely

established


PowerlessnessThis diagnosis is present when the individual per-ceives that his or her actions will not change a situa-

tion regardless of the options that the person maysee in a situation. Hopelessness occurs when the indi-vidual perceives that there are few or limited choicesin a situation. Powerlessness may evolve out ofHopelessness. Powerlessness is the perception thatone’s actions will not make a difference, whereasHopelessness is the perception that there are notoptions to act on. The decision about which is themost appropriate diagnosis is based on the clinicaljudgment of the nurse about which symptoms pre-dominate.

AnxietyAnxiety may have as a component a perception ofHopelessness. This could evolve out of the narrowedperception of the anxious client. Hopelessness mayhave Anxiety as a component. This situation coulddevelop when the client is feeling overwhelmed withthe perception that there are no alternatives in a diffi-cult situation. The primary diagnosis evolves from thesymptoms sequence. If Anxiety is the predominantsymptom cluster, it should be the primary diagnosisbecause of the strong influence it has on the client’sperceptions.

Disturbed Thought ProcessIf the individual cannot accurately assess the situa-tion, then a sense of Hopelessness might occur. Inthis instance, Hopelessness would be a companiondiagnosis.

FearIf the client is fearful in a situation, perception can benarrowed and alternative options may be overlooked.When Fear and Hopelessness occur together, Fearshould be the primary diagnosis.

EXPECTED OUTCOME

Expresses expectation of a positive future by [date].37

Develops [number] of personal goals by [date].37

Lists [number] reasons to live by [date].37


••••••


Home Health


Acknowledge all fears, feelings, and perceived threats asvalid to the client.

Administer anxiolytics as ordered, and educate the familyor caregivers about prescribed medications, their sideeffects, and scheduling.

Consult with and/or refer the patient to assistive resourcesas needed.

All client fears are valid to the client, whether they arerealistic or not.

Promotes a sense of well-being.

Utilization of existing services is an efficient use ofresources.


Hopelessness 563

••••••

TARGET DATES

A target date ranging between 3 and 5 days would be appro-priate for initial evaluation. A target date later than 5 days

might lead to increased complications, such as potential forself-injury. A target date sooner than 3 days would not pro-vide a sufficient length of time for realizing the effects ofintervention.


Adult Health


Establish a therapeutic and trusting relationship with thepatient and family by actively listening, being nonjudg-mental, sitting with the patient, etc.

Identify other primary care nursing needs, and deal withthese as needed.

Provide explanations and appropriate teaching for proce-dures, diagnosis, treatments, and prognosis.

Involve the patient in developing attainable goals andplan of care.

Assist the patient to identify positive aspects of thesituation

Support the patent’s efforts at objectively describingfeelings of hopelessness

Assist the patient to find alternatives to feelings of hope-lessness.

Hopelessness may prompt unhealthy eating patterns.(See nursing care plans related to ImbalancedNutrition and/or Fluid Balance.)

Support active participation in activities of daily living.Allow for preferences in day-to-day decisions (e.g.,establishing a bath time).

Refer to psychiatric nurse clinician as needed. (SeeMental Health nursing actions.)

Identify religious, cultural, or community support groupsprior to discharge. Provide appointments for follow-up.

Promotes an environment that encourages the patientand/or family to verbalize concerns. Promotes anempathetic environment.

Attention to basic needs may decrease feelings of hope-lessness and of being of no value.

Allows the patient to validate reality.

Validates reality and encourages use of alternate copingtechniques.

Helps restore sense of being in control.

Collaboration promotes a more holistic and completeplan of care.

Support groups can provide advocacy for the patient andcontinued monitoring and support of the patient afterdischarge from the hospital.

Child Health

Depending on the age and developmental status of the child, some components of Adult and Mental Health will also applyin addition to the following:


Monitor for the etiologic components contributing tohopelessness pattern.

Facilitate with patient and parents discussions of feelingsabout current status, with 30 minutes set aside eachshift at [times] for this purpose.

Assist the patient and family to explore growth potentialafforded by this specific experience.

Provides a database that results in a more accurate andcomplete plan of care.

Verbalization helps reduce anxiety and assigns value tothe patient’s concerns. Allows ongoing assessment.

Opportunity for growth may be overlooked in times ofcrisis.




••••••


Child Health


Allow opportunities for the child to “play out” feelingsunder appropriate supervision and guidance of childlife specialist:

• Play with dolls for toddler• Art and puppets for preschooler• Peer discussions for adolescents

Refer, as appropriate, to child mental health specialist.

Play and the acting out of feelings provide insight intocoping and perceptions of the child in a noninvasivemode. Provides valuable data to monitor feelings, con-cerns, etc.

Provides actual and anticipatory guidance for resolutionof the acute phase.

Women’s Health

l N O T E : The following nursing actions are for the couple (husband or wife) who hasbeen unable to conceive a child, after testing and treatment. See Chapter 10 for detailedinformation on infertility. Provide a nonjudgmental atmosphere to allow the infertilecouple to express their feelings such as anger, denial, inadequacy, guilt, depression,or grief.


InfertilitySupport and allow the couple to work through the

grieving process for loss of fertility, loss of children,loss of idealized lifestyle, and loss of feminine lifeexperiences such as pregnancy, birth, and breast-feeding.

Encourage the couple to talk honestly with one anotherabout feelings.

Encourage the couple to seek professional help if neces-sary to deal with feelings related to sexual relationship,conflicts, anxieties, parenting, and coping mechanismsused for dealing with loss of fertility (their expecta-tions, relatives’ expectations, and society’s expecta-tions).

Be alert for signs of depression, anger, frustration, andimpending crisis.

Provide the infertile couple with accurate information onadoption and living without children.

Postpartum Depression

Provision of support for and encouragement of discussionregarding emotions allows the couple to begin to dealwith emotions and lays the groundwork for future deci-sion making.44

Most adults assume they will have children; finding theycannot conceive often leads to feelings of inferiority,doubts about their sexuality, and guilt or blame.44

Allows early intervention and avoidance of complica-tions.44

Adoption choices in this country are limited becausemany single mothers are keeping their babies andbecause of the availability of birth control and abor-tion. Often couples in the United States look toforeign countries to adopt.44

l N O T E : The majority of patients who experience hopelessness that leads to postpar-tum depression have been found to have underlying psychiatric disorders, or life expe-riences other than pregnancy, that accounted for the depression.80


Hopelessness 565

••••••


Provide factual information to the patient and partner onpostpartum depression. Describe the differencebetween “baby blues” and depression. Identifypotential psychosocial triggers in the patient’senvironment that could lead to postpartumdepression, such as:

• Feelings of ambivalence• Feelings of inadequacy• Marital discord• Guilt and irritability

Domestic Violence80–84,88

Provide a nonjudgmental atmosphere that allows thepatient to express anger, fears, and feelings of hope-lessness. Refer the patient to an appropriate agency forassistance to find shelter and psychological counseling.Assist the patient in developing a plan of action in theevent of a situation that could threaten her or her chil-dren’s safety.

Place telephone numbers for assistance in the women’sbathroom and other places women can see andmemorize it without fear of reprisal from theirpartner.

Give the patient and partner realistic guidelines for whenthey might need to seek professional help for depres-sion beyond “baby blues.”80

Provides resources and information to patients withoutputting them or their children in further danger.

Mental Health


Monitor the health-care team’s interactions with the clientfor behavior (verbal and nonverbal) that would encour-age the client not to be hopeful (e.g., using an exampleof a less that optimal outcome of a disease processsuch as “I am a diabetic and am currently waiting formy kidney transplant,” or referring to adult incontinentunderwear as diapers). If situations are identified, theyshould be noted here, and the team should discussalternative ways of behaving in the situation. Theactions needed to support the client’s hope should benoted on the client’s chart.

Sit with the client [number] times per day at [times]for 30 minutes to discuss feelings and perceptions theclient has about the identified situation. These timesshould also include discussions about the client’s sig-nificant others, times the client has enjoyed with thesepersons, the projects or activities the client was plan-ning with or for these persons that have not beenaccomplished, the client’s values and beliefs abouthealth and illness, and the attitudes about the currentsituation.

Negative attitudes from the staff can be communicated tothe client.

Promotes positive orientation by assisting the client inremembering past successes and important aspectsof life that make it important that he or she succeedthis time.89,90




••••••


Mental Health


Identify with the client’s significant others times that theycan talk with the staff about the current situation.Themes that should be explored during this interactionshould be their thoughts and feelings about the currentsituation, ways in which they can support the client,the importance of their support for the client, questionsthey may have about the client’s situation, and possibleoutcomes. (Note the time for this interaction here aswell as the name of the person who will be talkingwith the significant others.)

Note the times when significant others will be visiting,and schedule this time so there will be a private timefor them to interact with the client. (Note these timeshere, and designate those times that are scheduled asprivate visitation times.) Inform the client and signifi-cant others of places on the unit where they can haveprivacy to visit.

Identify with the client preferences for the daily routine,and place this information on the chart to be imple-mented by the staff. It is vital to this client to have theinformation shared with all staff so that it will notappear that the time spent in providing information waswasted.

Provide answers to questions in an open, direct manner.

Provide information on all procedures at a time when theclient can ask questions and think about the situation.

Allow the client to participate in decision making at thelevel to which he or she is capable of doing so. A clientwho has never made an independent decision would beoverwhelmed by the complexity of the decisions madedaily by a corporation executive. If necessary, offerdecision situations in portions that the client can mas-ter successfully (the amount of information that theclient can handle should be noted here as well as a listof decisions that have been presented to the client).

Provide positive reinforcement for behavior changed anddecisions made. The actions that are reinforcing for thisclient should be listed here along with the reward sys-tem that has been established with the client (e.g., playone game of cards with the client when a decision aboutways to cope with a specific problem has been made).

Provide verbal informative social reinforcements alongwith behavioral reinforcements.

Keep promises (specific promises should be listed on thechart so that all staff will be aware of this information).

Accept the client’s decision if the decision was given tothe client to make. These decisions should be noted onthe chart.

Negative expectations from the support system can becommunicated to the client.

Assists the client in maintaining connections with thesupport systems, and increases the awareness of contri-butions the client has made in the past and can make inthe future to this system.


Promotes the client’s sense of control, while building atrusting relationship.

Promotes the client’s sense of control in a manner thatincreases the opportunities for success. This successserves as positive reinforcement.

Positive reinforcement encourages behavior whileenhancing self-esteem.

Promotes the development of a trusting relationship.Enhances self-esteem.89

Promotes the client’s sense of control, while enhancingself-esteem.


Hopelessness 567

••••••


Provide ongoing, informative, positive feedback to theclient on progress.

Spend 30 minutes a day talking with the client about cur-rent coping strategies and exploring alternative copingmethods. Note the time for this discussion here as wellas the person responsible for this interaction. Whenalternative coping styles have been identified, this timeshould be used to assist the client with necessary prac-tice. The alternative styles that the client has selectedshould be noted on the chart, and the staff should assistthe client in implementing the strategy when appropri-ate. These could include deep muscle relaxation, visualimagery, prayer, or talking about alternative ways ofcoping with stressful events.

Allow the client to express anger, and assist with discov-ering constructive ways of expressing this feeling (e.g.,talking about this feeling, using a punching bag, play-ing Ping-Pong, or throwing or hitting a pillow). Talkwith the client about signs of progress, and assist himor her in recognizing these as they occur with verbalreminders or by keeping a record of steps taken towardprogress.

Assist the client in establishing realistic goals and realis-tic expectations for situations. The goals should beshort term and stated in measurable behavioral terms.Usually, dividing the goal set by the client in half pro-vides an achievable goal. This could involve dividingone goal into several smaller goals. [Note goals andevaluation dates here.]

Determine times with the client to evaluate progresstoward these goals and to discuss his or her observa-tions about this progress. These specific times shouldbe listed here with the name of the person responsiblefor this activity. Initially this may need to be done on adaily basis until the client develops competency inmaking realistic assessments.

Assist the client in developing a list of contingencies forpossible blocks to the goals. These would be “what-if”and “if-then” discussions. This would be done in thegoal-setting session, and a record of the alternativesdiscussed would be made in the chart for futurereference.

Discuss with the client values and beliefs about life, andassess the importance of formal religion in the client’slife. If the client requires contact with a person of hisor her belief system, arrange this, and note necessaryinformation for contacting this person here. Provide theclient with the time necessary to perform religious ritu-als that are important to him or her. Note the ritualshere with the times scheduled and any assistance that isrequired from the nursing staff.

Provides positive reinforcement for accomplishments.89

Interaction with the nurse can provide positive reinforce-ment. Behavioral rehearsal provides opportunities forfeedback and modeling of new behaviors from thenurse.

Promotes the development of a positive orientation.

Goals that are achieved serve as positive reinforcementfor behavior change and enhance self-esteem and apositive expectational set.

Provides positive reinforcement for movement toward thegoal, and provides an opportunity for the nurse to pro-vide positive verbal reinforcement.

Provides direction for the client, with an opportunity tomentally rehearse situations that could require alter-ation of goals. This protects the client from all-or-nonesituations.

Spirituality can provide hope-giving experiences.




••••••


Mental Health


Provide the client with opportunities to enjoy aestheticexperiences that have been identified as important,such as listening to favorite music, having favorite pic-tures placed in the room, enjoying favorite foods, orhaving special flowers in the room. Spend 5 minutesthree times a day discussing these experiences andassisting the client in becoming involved in the enjoy-ment of them. Note here activities that have been iden-tified by the client as important and times when theywill be discussed with the client.

Assist the client in developing an awareness and anappreciation for the here and now by helping him orher focus attention in the present by pointing out tohim or her the beauty in the flowers in the room, thewarmth of the sunshine as it comes through the win-dow, the calmness or vitality of a piece of music, thetaste and smell of a special food item, the odor of flow-ers, etc.

Establish a time to talk with the client about maximizingpotential at his or her current level of functioning. Notedate and time for this discussion here. This may needto be done in several stages during more than one time,depending on the client’s level of denial. Note here theperson responsible for these discussions.

Promotes the client’s interest in the positive aspect of life,promoting a positive orientation.

Provides the client with an opportunity to access pastpositive experiences in the present, thus promoting apositive orientation.

Promotes the client’s sense of control, enhancing self-esteem.

Gerontic Health

The nursing actions for the older adult with this diagnosis are the same as for the Adult Health and Mental Health patient.

Home Health



Monitor for factors contributing to the hopelessness (e.g.,psychological, social, economic, spiritual, or environ-mental factors).

Involve the client and family in planning, implementing,and promoting reduction or elimination of hope-lessness:

• Family conference: To identify and discuss factors con-tributing to hopelessness

• Mutual goal setting: Setting goals with roles of eachfamily member identified

• Communication• Support for the caregiver

Provides a database for early recognition and inter-vention.

Clarifies roles. Personal involvement in planning, etc.Increases the likelihood of success in resolving theproblem.


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